Leading patient safety advocates assess progress in reducing medical error five years after landmark IOM report

May 18 2005

It has been five years since the release of the Institute of Medicine’s landmark report on medical errors, “To Err is Human.” What progress has been made to improve patient safety since the report found that nearly 100,000 deaths occur annually as a result of medical error?

Two of the authors of the report, Lucian Leape, adjunct professor of health policy and management at the Harvard School of Public Health (HSPH) and Donald Berwick, CEO of the Institute for HealthCare Improvement, outline the progress and the challenges that face America’s health care system in a paper appearing in the May 18, 2005 issue of the Journal of the American Medical Association. 

The authors found that the report had a positive impact in three important areas of health care; how health care views the task of error prevention, enlisting support of stakeholders and changing practices. Prior to the publication of To Err is Human, blaming individuals for medical injury and error was the norm, but the authors find that attitude has given way to the concept that bad systems, not bad people, lead to the majority of medical injuries and errors.

Another major effect of the report was signing up key health care organizations to get together to improve patient safety, starting with the federal government. Congress, in 2001, appropriated $50 million for patient safety research, enabling hundreds of new investigators to pursue patient safety research and establish it as a legitimate academic area of study. Since 2004, funding has been redirected toward information technology, however Congress did name the Agency for Healthcare Research and Quality (AHRQ) as the lead federal agency for patient safety. AHRQ established the Center for Quality Improvement and Safety, which has become the nation’s leading source for education, training, disseminating information, developing measures and facilitating the setting of standards for furthering patient safety efforts.

Other non-governmental organizations have followed the lead of the AHRQ, adopting and establishing guidelines and procedures for furthering patient safety and reporting medical errors, among them; The Joint Commission on Accreditation, The National Quality Forum, The Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, the American College of Physicians, the National Patient Safety Foundation, the Accreditation Council on Graduate Medical Education, the American Board of medical specialties and the Institute for Healthcare Improvement.

While the authors note the progress that has been made they point out some of the issues that are keeping the pace of improvement moving slowly, such as the complexity of the medical industry, the commitment to professional autonomy in medicine, fear of malpractice for admitting error, a lack of leadership at the hospital and health plan level and a paucity of definable measures to demonstrate that improvement is being achieved.

Some of the notable highlights of clinical effectiveness of safe practices that have been implemented in individual hospitals since the IOM report:

• Computerized physician prescribing decreased medical errors by 80%.
• Including pharmacist with medical team reduced preventable adverse drug events by 78%
• Standardizing medication practices reduced adverse drug events by 60%
• Team training in labor delivery reduced adverse outcomes in preterm deliveries by 50%
• Rapid Response Teams reduced cardiac arrests by 15%
• Perioperative antibiotic protocols reduced surgical site infections by 93%

Co-author Lucian Leape said, “While the progress that has been made in improving patient safety is encouraging, it has been much too slow.  Hospitals need to have crash programs to implement the many safe practices that we now have evidence work.  We will not become safe until we put that knowledge into practice. To accelerate progress we need to align the forces for change.  The best way to do that would be for the major national organizations, federal and private, to set explicit, ambitious, quantitative national goals and call for all health care organizations to meet them.” He added, “We will not make health care safe until we choose to make it safe.”

The full text of To Err is Human: Building a Safer Health System can be viewed here:http://books.nap.edu/books/0309068371/html/

The research was supported in part by the Commonwealth Fund.