To Err is Human Banner

Jump to:

To Err is Human book cover

The IOM report opened America's eyes to the problem of medical error.

Image Source: IOM

If three jumbo jets crashed every two days killing all passengers, people would take notice and demand change. However, roughly the same number of people die each year from medical errors: a reported 44,000 to 98,000 deaths per year. The Institute of Medicine (IOM) published the report "To Err is Human: Building a Safer Health System" in 2000 with these statistics. A few years earlier, NY Times reporter Michael Weinstein compared the number of deaths from medical error to those jumbo jets crashing every other day. He noted that, "If the airlines killed that many people annually, public outrage would close them overnight. [When hospitals do it] there's hardly a whimper of protest" (Weinstein, 1998). The IOM report was aimed at informing the public of the harsh realities of the statistics of medical error by bringing together government, healthcare providers, industry, and consumers to create change.

Introduction

The IOM published the report after two large-insurance sponsored studies and numerous media reports highlighted the frequency and severity of preventable medical errors in the US (Sharpe 2004). The report outlined numerous recommendations to improve patient safety. The IOM defined safety as "freedom from accidental injury" and stated that,

[It] is not acceptable for patients to be harmed by the healthcare system [and] that is supposed to offer healing and comfort (Kohn, Corrigan, & Donaldson 2000).
The stated goal was to reduce error by 50% over 5 years. This target was justified by the fact that these preventable medical errors came with a national price tag of $17 billion to $20 billion per year (Kohn, Corrigan, & Donaldson 2000).

to top

First Tier

US Congress

The IOM recommended congressional actions to help solve the rising problem of medical errors.

Image Source: Kidport

The report was structured to address concerns at the policy level through government intervention. The first tier of recommendation was to create a national focus with leadership, research, and protocols for patient safety (Kohn, Corrigan, & Donaldson 2000). Healthcare is behind other industries, such as occupational safety, in part because there is no designated agency to establish and communicate priorities for safety (Sharpe 2004). The IOM recommended this be ameliorated by creating a center for patient safety under the Agency of Health and Human Services to launch and oversee national patient safety goals.

Congress endorsed the Agency for Healthcare Research and Quality (AHRQ) which created the Center for Quality Improvement and Safety. Additionally, non-governmental organization such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented new safety requirements for healthcare facilities updated yearly. Current requirements include using two forms of patient identification and banning certain abbreviations or symbols that can be easily misunderstood (Joint Commission 2007).

to top

Second Tier

doctor at computer

Reporting errors allows facilities nationwide to learn from one isolated incident.

Image Source: X-Link

The second tier recommended standardized, mandatory, public reporting of serious medical errors and encouraged voluntary reporting of 'near-misses' that had the potential to cause serious harm. Reporting of errors allow for facilities nationwide to take preventative measures. For example, if an error or near error occurs because two syringes of different clear liquids were placed unlabeled on an equipment tray, reporting the error would allow other facilities nationwide to see the potential harm of not labeling the syringes and it allows them to learn without committing the error directly. Anticipating the legal ramifications that go along with reporting of errors, the IOM also recommended the legal protection for peer review be extended to data related to patient safety and quality improvements, "for internal use or shared with other solely for the purposes of improving safety and quality" (Kohn, Corrigan, & Donaldson 2000). With this extended legal protection, the rate of error reporting would increase and the medical community would have more to learn from.

to top

Third Tier

Thirdly, the report recommends that patient safety become a measure of performance for healthcare organizations and practitioners, effectively raising standards and expectations. The IOM emphasized that in order for change to occur, institutions and professional societies must place special attention on continually improving patient safety by reviewing and studying reported errors. The report specifically mentioned that the FDA, responsible for regulating safety and effectiveness of drugs and devices, should increase their attention to safety. The FDA took the recommendation and currently exercises greater caution in reviewing drugs and devices. Professional societies and peer reviewed medical journals now feature articles and awareness on medical error, patient safety, and new associated mandates regularly. The articles and increased awareness educate health professionals about new issues in patient safety.

Staff of Medical Professionals

Errors are not generally caused by one person but rather by a series of errors made my multiple individuals.

Image Source: Western Piedmont Medical Professionals

Fourth Tier

The report emphasized the role that systems play in medical error and declared that the majority of errors are caused by "faulty systems, processes, and conditions" rather than one "bad apple" of an individual or group acting recklessly (Kohn, Corrigan, & Donaldson 2000). The IOM recommended human factors research to study interactions between humans, the tools they use, and the environment in which they work that may be at the root of some errors. The report encouraged healthcare organizations develop a "culture of safety" which have been implemented nationwide by simplifying and standardizing procedures and improving team communication (Kohn, Corrigan, & Donaldson 2000).

to top

Additional Recommendations

While the IOM recognized the role of ethics, they concluded that internal motivations alone could not solve the problem. They suggested purchasers of healthcare, insurance companies, and individuals focus on safety to create financial incentives for institutions to reduce medical errors. After the report was published, a wide variety of stakeholders worked to improve patient safety. Congress allocated $50 million annually for patient safety research with the majority of the funds going to IT (Leape & Berwick 2005). Critics have asserted that this pales in comparison to the $1 billion the Canadian government has given to information technology (IT) research alone and that the funds should be spread across a variety of areas instead of focusing on IT (Leape & Berwick 2005; Young 2005).

The IOM aimed to create external regulatory and economic forces to provide, sufficient pressure to make errors so costly...that [healthcare] organizations must take action (Kohn, Corrigan, & Donaldson 2000).

Numerous specialty societies now feature safety topics in discussions, meetings, and research. The Institute for Healthcare Improvement has assisted hospitals in redesigning systems and training for safer practice of medicine (Leape & Berwick 2005). Purchasers and payers have entered the arena as well. The Leapfrog Group, comprised of US Business Roundtable companies, urges facilities to use computerized physician order entry systems, staff ICUs with intensivists around the clock, and concentrate high risk procedures in high volume facilities to reduce error (Leapfrog Group). The IOM aimed to create external regulatory and economic forces to provide, sufficient pressure to make errors so costly...that [healthcare] organizations must take action (Kohn, Corrigan, & Donaldson 2000). The surge of action on the part of healthcare organization to reduce error is proof that the regulatory and economic forces have been created and are working effectively.

to top

Have Improvements Been Made?

Pills

Medication errors are still occurring in very large numbers.

Image Source: Tab Tote

While it is clear that improvements have been made, lack of clear data and analysis, as well as multiple criticisms on the validity of the original numbers, have made if difficult to measure if patient safety improvements were made between 2000 and 2005 (Harrington 2005; Young 2005) A joint study cited that 55% of Americans were dissatisfied with the quality of healthcare in 2005, an 11% increase from 2000 when the report was published (Young 2005). The increase is likely explainable by the surge of attention placed on patient safety in the aftermath of the report. Certain areas such as medication errors have increased from 40,000 in 2000 to 90,000 in 2005 (Joint Commission). It is difficult to solve patient safety problems given the ever changing nature of medical science and the continual occurrence of medical errors today prove that there is still a great deal of work to be done in order to improve patient safety.

By simply bringing the statistics on medical error to the nation's attention, the IOM report changed the way healthcare professionals think about and discuss medical errors. The severity of the problem is widely known and understood allowing us to move on to ask what we can do about the problem instead of questioning if a problem exists (Leape & Berwick 2005).

to top

Future

The IOM recognizes that there is still room for improvement.

They have issued a new list of goals for 2010 that calls for a 90% reduction in nosocomial (hospital acquired) infections, 50% reduction in medical errors, 90% reduction in errors associated with high harm medications, an 100% elimination of the NQF 'never list' of error that should never occur, such as surgery performed on the wrong body part (National Quality Forum 2003).

As modern healthcare and technology advance, safety is becoming a complex, changing issue. Oftentimes science moves too fast for appropriate safety measures to keep up. Advances in the creation of electronic health records, the diffusion of successful safety programs and practices, and the continuous reporting of actual and potential medical errors will bring the healthcare system into the new generation of patient safety and hopefully help it to meet the 2010 goals. While improvements have been made, the number of medical errors is still too large. It is important to continue reporting and reviewing errors as well as studying and modifying the systems that lead to errors. Patient safety needs to be studied more in depth so that it can advance at the same rate as medical science. One of the biggest results of the IOM report was to create public awareness of patient safety to help begin to fix the problem.

to top

Works Cited

to top