Senate Hearing Assignment

As you watch the Senate Hearing, answer the following questions:

1. What is the reason for the Senate Hearing? 

Preventable medical errors in hospitals is known as the the third unknown leading cause of death of the United States. According to an article in the Journal of Patient Safety as many as 440,000 people a year may die from preventable medical errors in hospitals (The U.S. Senate Committee on Health, Education, Labor & Pensions, 2014). 

2. Fill in the following table:

Who are the stakeholders at the Hearing?	What message/background information is provided to the Senators?	What key recommendations do the deliver?	Are they an effective communicator? Why?
Dr. John James	As a result of the neglect and safety issue surrounding the health care sector the doctor lost his child and this led him into being a patient activist. The matter could have been avoided if doctors were keener in their assessment and diagnosis.	The Senate should establish a standalone committee on improving patient safety. 2. The Senate should establish a National Patient Safety Board. 3. It should pass a national patients’ bill of rights to include:legally defined and enforced rights to give genuinely informed consentto know the safety record of their physician, outpatient clinic, nursing home, and hospitalto know costs  for tests and elective procedures beforehandto transparent accountabilityto evidence-based careto know when drugs are prescribed off-labelto be warned about bad lifestyle choicesto have care by teams of professionals that build individual and team excellence through 360-degree performance reviews.	Yes. He speaks based on his personal experience and research.
Dr. Ashish Jha	There has not been enough progress in improving patient safety in the last fifteen years. The problem is not unique to the United States but more needs to be done. The CDC can help develop validated metrics of infections and feeding that information back to hospitals.	To have real progress we need to do 3 things:Expand the effort of CDC through its surveillance programs.As electronic record system is being implemented, make sure this tool is designed to focus on improving patient safety.The incentives should be used to improve safety, especially by large payers like Medicare.	For the most part Dr. Jha was well spoken and effective.
Dr. Tejal K. Gandhi	Most of healthcare is provided outside of hospitals, which include primary care and specialist practices, nursing homes, rehabilitation centers, dialysis centers, and ambulatory surgical centers	Three areas of importance are medication safety, missed and delayed diagnosis, and transitions of care. In the area of medication safety 25% of patients are non-adherent.Inappropriate test and failure to follow up the results.  A better system needs to be implemented that prevents medical errors and brings to attention of healthcare workers.	Yes. She was clear in her explanation at the Senate.
Dr. Pronovost	Change needs to be placed and emphasized on the patient safety regulations in the country and this has to be done by changing the laws that govern the medical aspect of the whole regulatory anatomy	Four areas of importance have been covered by the doctorPlacing and creating monitoring systems that also include the public.Creation of healthcare standards which will aid in reporting the cost and quality of healthcare measures, which will be similar to action taken on the Securities and Exchange Act of 1934Offer support to AHRQ to be able to advance the science of patient safety to make sure that there is a workforce that has training that is similar to Tejal and AshishInvesting in systems engineering and learning labs, which are meant to improve safety and productivity.	Yes. He was well spoken and precise and also very discernable.
Ms.Disch	The scope needs to be widened and not only look at the 1,000 preventable deaths in a day but also the prevention of 10,000 preventable complications a day and this will aid in improving the quality of life in regard to healthcare.	There are three areas that have been made important Ensure that there are enough nurses who are registered and well educated, who have a voice, and are able to make decisions about patient care at the bedside and also staffing Engaging the patient and family as full partners in care. Culture of healthcare should be committed to that of safety	Yes. Precise and very clear to the core issues.

3. Why is there not more awareness regarding unintended medical harm?

The doctors, nurses and other professionals should stop taking the blame as it has been seen before.

There needs to be more emphasis on the culture among the practitioners and also the state of the medical healthcare system. 

An increase in public awareness on prevention of medical safety also needs to be in the agenda. 

There needs to be more awareness about the public accounts, healthcare workers and hospital accounts.

4. What is the level of public transparency on patient outcomes?

The current situation is that there is not as much public transparency in regard the outcome of the patients’. This problem is very rampant in areas that do not have a hospital setting. There needs to be accountability in the case of adverse events.

5. What are some of the barriers to decreasing medical errors?

The systemic barriers and the time pressures make it difficult to do the right thing and also due to the time pressure, quick fixes become the alternative and this does not solve the root problems. System barriers make doing the right thing hard, and time pressures reinforce doing things quickly without fixing underlying problems. 

Speaking up in the past due to certain fears has discouraged people from calling out the healthcare system from the systemic point of view.

Provider’s autonomy:  Instead of doing what a medical expert wants to do he/she should use evidence based practice.

6. What are some of the solutions to decreasing medical errors?

1. The Senate should establish a standalone committee on improving patient safety.
2. The Senate should establish a National Patient Safety Board.
3. The Senate should pass a national patients’ bill of rights to include 

1. Legally defined and enforced rights to give genuinely informed consent; to know the safety record of their physician, outpatient clinic, nursing home, and hospital; to know costs for tests and elective procedures beforehand; to transparent accountability; to evidence-based care; to know when drugs are available or not.
2. Prescribed off-label; to be warned about bad lifestyle choices; to have care by teams of professionals that build individual and team excellence through 360-degree performance reviews. 

References

More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety: The U.S. Senate Committee on Health, Education, Labor & Pensions. (n.d.). Retrieved from https://www.help.senate.gov/hearings/more-than-1-000-preventable-deaths-a-day- is-too- many-the-need-to-improve-patient-safety.