Why Reporting Is Not Enough: Improving the Patient Safety and Quality Improvement Act of 2005 47 University of Toledo Law Review 2015-2016

47 U. Tol. L. Rev. 475 (2015-2016)
Why Reporting Is Not Enough: Improving the Patient Safety and Quality Improvement Act of 2005

handle is hein.journals/utol47 and id is 491 raw text is:

WHY REPORTING IS NOT ENOUGH: IMPROVING THE
PATIENT SAFETY AND QUALITY IMPROVEMENT ACT
OF 2005

Mason H. Forrest*

I. INTRODUCTION

W HAT causes the deaths of over 400,000 people in the United States
every year? Medical error.' The Institute of Medicine (the IOM)
estimates medical errors cause injuries to 1.5 million people per year.2 These
errors take the lives of innocent patients, like I1-year-old Leah Alexander.3
While recovering from a successful surgery, Leah received increasing doses of
narcotics and anxiety medication.4 During these few days, a nurse or doctor on
rounds was monitoring her vital signs visually without comparing the machines
monitoring her heart rate and respiration. The provider failed to appreciate how
low Leah's heart rate and respiration were becoming until Leah passed away-
from an entirely preventable Fentanyl overdose.6 Stories like Leah's are the
reason the Patient Safety and Quality Improvement Act of 2005 (the PSQIA)
was created.
Though created with the promise of reducing the instances of medical error,
the PSQIA has yet to effectuate a noticeable reduction in medical error in the
United States. To achieve the desired reduction in medical error, Congress needs
to first appoint a central governing body to provide accountability for healthcare
providers and institutions alike. This body would propose amendments to the
PSQIA, which should include mandating both the use of checklists and active
membership in a patient safety organization (PSO) for every healthcare
institution in the United States. Part II of this Article describes the creation of the

* Juris Doctor 2015 from University of Kentucky College of Law.
1. John T. James, A New, Evidence-Based Estimate of Patient Harms Associated with
Hospital Care, 9 J. PATIENT SAFETY 122, 122 (2013).
2. Anna Medaris Miller, 5 Common Preventable Medical Errors, U.S. NEws & WORLD REP.,
(May 30, 2015, 4:18 PM), http://health.usnews.com/health-news/patient-advice/slideshows/5-
common-preventable-medical-errors/2.
3. Nicholas J. Valeriani, A Mother's Mission to End Preventable Medical Errors, W. HEALTH
(May 15, 2015), http://www.westhealth.org/news/a-mothers-mission-to-end-preventable-medical-
errors/.
4. Id.
5. Id.
6. Id.
7. Patient Safety and Quality Improvement Act of 2005, Pub. L. No. 109-41, 119 Stat. 424
(codified at 42 U.S.C. § 299b-21 (2005)).

475

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