March 29, 2001

The Honorable George H. Ryan
Governor
207 State House
Springfield, Illinois 62706

Dear Governor Ryan:

As Chair of the Task Force on Patient Safety, I am pleased to present you with the recommendations of the Task Force. When you appointed this panel of experts November 22, 2000, you charged us to examine issues related to medical errors in Illinois and to make recommendations for improvement of health service delivery systems specific to eight areas:

• Staffing levels,
• Performance of specified activities by licensed staff only,
• Assuring qualifications and competence of staff for specified units within hospitals,
• Reporting System,
• Coordination/Information Sharing between State agencies,
• Clearinghouse for Best Practices,
• Reporting of Repeat Offenders to the Department of Professional Regulation, and
• Drug and Alcohol Impaired Health Care Providers.

Addressing patient safety issues must be a priority of the State of Illinois. The National Academy for State Health Policy, using data extrapolated from the landmark Institute of Medicine report, To Err is Human: Building a Safer Health Care System, estimates that 4,730 Illinois residents die each year - 13 per day - from medical errors. The report states that the cause of medical errors is rarely negligent or careless health care providers. Rather, medical errors usually result from inadequately designed health care delivery systems and processes. Accordingly, redesign of health care delivery systems and processes must be encouraged.

The Institute of Medicine report finds that the best way to identify and address health care delivery system and process errors is to collect and analyze information. To this end, the Task Force on Patient Safety recommends that:

• hospitals should be mandated to report health care delivery system and process errors to a central depository,

• that error-related information be evaluated to identify systemic problems and best practices to address those systemic problems, and

• that best practices be identified and implemented across all hospitals on a continuous quality improvement basis.

Finally, the Task Force on Patient Safety supports the Institute of Medicine finding that the reporting of health care delivery system and process errors occur in a non-punitive environment which does not punish health care professionals and providers for reporting problems. It is necessary to replace the current culture of blame with a culture of safety that encourages and supports reporting and learning.

In our deliberations, the Task Force identified additional areas which may warrant future study. Additionally, given the speed with which we were charged to make our recommendations, there may be issues within our eight areas of study which would benefit from further study and analysis. The Task Force stands ready to assist you in whatever manner you deem appropriate to ensure that Illinois' healthcare service delivery system is safe for all of our citizens.

                                                                                                                Sincerely,

                                                                                                               Carl Getto, M.D., Chair
                                                                                                               Governor's Task Force                                                                                                                on Patient Safety