Executive Order

WHEREAS, on February 6, 2003, the director of the Missouri Department of Insurance issued the report "Medical Malpractice in Missouri: The Current Difficulties in Perspective;" and

WHEREAS, past proposals to deal with medical malpractice insurance crises have focused almost exclusively on tort reform and insurance industry reform, and

WHEREAS, it is equally appropriate to focus on problems such as inadequate provider/patient communications, improper clinical and administrative procedures, and preventable medical errors, which taken together, are the cause of many medical malpractice claims; and

WHEREAS, it is important to strike a balance between public accountability for the quality of health care and the need for health care providers to learn from medical errors.

NOW, THEREFORE, I, Bob Holden, Governor of the State of Missouri, by virtue of the authority vested in me by the Constitution and the Laws of the State of Missouri, do hereby establish the Missouri Commission on Patient Safety, the composition of which shall be as follows:

The directors of the Department of Insurance and the Department of Health and Senior Services; the executive director of the State Board of Registration for the Healing Arts; 16 persons appointed by the Governor from a variety of professions and perspectives including, but not limited to, physicians, osteopathic physicians, pharmacists, nurses, hospital administrators and staff, risk managers, long-term care administrators and staff, medical educators, patient care review specialists, patient safety and quality improvement professionals, and health care consumers, and such other members as the Governor may from time-to-time appoint. The Governor will designate one member of the commission as chairperson and one member as vice-chairperson.

The purpose of the commission shall be to study and recommend legislative, administrative, clinical, behavioral, and technological measures to improve medical outcomes, prevent errors, upgrade health-care delivery systems, and improve education of medical providers and patients, all with a goal of reducing the incidence of preventable medical errors and reducing the number of medical malpractice claims.

The commission is assigned to the Missouri Department of Insurance for administrative purposes. Members of the commission shall serve without compensation but may be reimbursed for reasonable and necessary expenses arising from the commission's activities.

The commission will report its recommendations to the Governor by March 1, 2004.

IN WITNESS WHEREOF, I have hereunto set my hand and caused to be affixed the Great Seal of the State of Missouri, in the City of Jefferson on this 1st day of October, 2003.

[Bob Holden's signature]
Bob Holden


[Matt Blunt's signature]
Matt Blunt
Secretary of State

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