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patrolling, reporting, and analysis of healthcare phenomena—
particularly adverse incidents (such as the event giving rise to
the peer review in Bredice) and so-called “near misses”—will
allow providers and policymakers to locate, and ultimately fix,
the mechanisms that allowed for the error in the first place.^119
The 1999 Institute of Medicine Report, To Err is Human:
Building a Safer Health System, which alarmingly estimated that
between 44,000 and 98,000 Americans died each year as a result
of preventable medical errors,^120 effectively launched the Patient
Safety Movement in America.^121 Within months of publication,
President Clinton called for the creation of nationwide error-
reporting systems and mandated the introduction of patient safety
programs for hospitals participating in Medicare.^122 Federal and
state agencies, hospitals, and other health providers followed
suit, initiating mandatory reporting systems, improved health
records systems, and other policies attempting to root out errors
in medicine.^123 In 2005, Congress passed the Patient Safety and
Quality Improvement Act of 2005 (“PSQIA”),^124 which created
Patient Safety Organizations (“PSOs”) “to collect, aggregate,
and analyze confidential information reported by health care
providers” on a privileged and confidential basis, for analysis of
trustworthy system of health care delivery” and as “an attribute of health care
systems; it minimizes the incidence and impact of, and maximizes recovery
from, adverse events”).
(^119) See id. at 2, 5–6; see also N.J. STAT. ANN. § 26:2H-12.24(d) (West
2007 & Supp. 2012); George J. Annas, The Patient’s Right to Safety—
Improving the Quality of Care Through Litigation Against Hospitals, 354
NEW ENG. J. MED. 2063, 2065 (2006).
(^120) NAT’L RESEARCH COUNCIL, TO ERR IS HUMAN: BUILDING A SAFER
HEALTH SYSTEM 1 (2000).
(^121) See Bob Wachter, The Patient Safety Movement Turns Ten, HEALTH
CARE BLOG (Dec. 2, 2009), http://thehealthcareblog.com/blog/2009/12/02/
the-patient-safety-movement-turns-ten/.
(^122) Fred Charatan, Clinton Acts to Reduce Medical Mistakes, 320 BRIT.
MED. J. 597, 597 (2000).
(^123) See generally Lucian Leape & Don Berwick, Five Years After To Err
Is Human: What Have We Learned?, 293 JAMA 2384 (2005).
(^124) The Patient Safety and Quality Improvement Act of 2005, Pub. L.
109-41, 119 Stat. 424 (codified in scattered sections of 42 U.S.C.).