IOM report To Err is Human
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PUBLISHED February 1, 2020 • Print-Friendly The Institute of Medicine (IOM, now known as the National Academy of Medicine) 20 years ago published the landmark report, To Err Is Human: Building a Safer Health System. This report increased awareness of medical errors in the U.S. and also called for health care system changes that would lead to improvements in patient safety and quality of care. Show The report cited a study that estimated at least 44,000 patients die annually in the U.S. as a result of medical errors, with an additional study suggesting it could be as high as 98,000.1 The report also stated that deaths attributed to medical errors exceeded “the number attributable to the eighth-leading cause of death,” which at the time was suicide.1-3 More importantly, the report highlighted the fact that most medical errors were the result of failures of the system rather than specifically attributable to individuals.1 Still work to be doneTwo decades later, Mark R. Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission—a member of the IOM Committee on Quality of Health Care in America that wrote the To Err Is Human report—believes that although that report and others have led to improvements in the health care system, the rates of familiar quality issues remain too high. For surgeons, quality issues that still demand attention include wrong-site surgery and the continued incidence of unintended retained foreign objects (URFOs). URFOs were the top sentinel event reported to The Joint Commission in 2017 (124 reported) and again in 2018 (121 reported). A total of 104 incidents of wrong-patient, wrong-site, wrong-procedure events were reported in 2017, with another 98 reported in 2018. Dr. Chassin touched on the To Err Is Human report and more in a Modern Healthcare editorial, “One-size-fits-all approach to patient safety improvement won’t get us to the ultimate goal—zero harm.” Dr. Chassin laid out three changes health care leadership can make to ensure patients receive higher quality care. They are as follows:3
In the Modern Healthcare commentary, Dr. Chassin also wrote that “the method we have employed is the ‘one-size-fits-all’ best practice.”3 But that approach often leads to modest or inconsistent improvements that are difficult to sustain over time. “We cannot continue to use the same methods and expect different results,” Dr. Chassin wrote. “Evidence is accumulating that process improvement methods long used successfully in industry—Lean, Six Sigma and change management, taken together—are far more effective than the ‘one-size-fits-all’ best-practice approach.”3 Dr. Chassin also spoke with Nancy Foster, American Hospital Association vice-president for quality and patient safety, for the Advancing Health podcast. In the episode, Dr. Chassin described the impact of the To Err Is Human report on health care safety.4 Now what?So where do we go from here? In a recent High Reliability Healthcare blog post, Dr. Chassin reflected on the future impact of To Err Is Human and how health care can continue to improve. “We’ve made some significant progress, but the next major gains will arise only from the efforts of health care leadership and organizations, not government, business, market forces, nor patient advocacy groups,” Dr. Chassin wrote.5 He also asked that after 20 years, “Who is satisfied with the current state?” He noted, “If we’re not satisfied, we need to change the way we have been going about improvement.”5 The report marked a pivotal moment in the health care industry, policymaking, and society’s expectations about how health care is provided. My personal take on the IOM report is positive. I believe that before the report was published, health care leaders were primarily focused on innovation. The report marked a pivotal moment in the health care industry, policymaking, and society’s expectations about how health care is provided. Starting in early 2000 (the report was released in November 1999), attention rapidly shifted from a focus on innovation as a way to advance health care to a focus on safety. That movement toward safety has grown ever since, and that, I believe, has provided enormous benefits to our patients.6 Am I satisfied with the rate of harm surgical patients continue to experience? Of course not. However, safety is not a static goal line but rather a moving target. New processes, new devices, new ways of providing treatment—yes, innovation—continues full throttle, and while these advances have benefited society in a significant way, they also have created vulnerability and risks that were not present before. Managing those risks, creating a culture of safety, and continuing to focus on ways to identify and eliminate threats before they become errors is, in my view, the greatest legacy of this report and a moral imperative for every surgeon. DisclaimerThe thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons. References
Tagged as: quality improvement, The Joint Commission, To Err Is Human ContactWhat did the IOM errors report show?The Institute of Medicine (IOM) released a report in 1999 entitled “To Err is Human: Building a Safer Health System”. The report stated that errors cause between 44 000 and 98 000 deaths every year in American hospitals, and over one million injuries.
What was the government's response to the Harvard report To Err Is Human?Soon after the release of To Err Is Human, Congress passed legislation requiring the Agency for Healthcare Research and Quality (AHRQ) to issue annual reports designed to monitor progress in improving care.
How do you reference to err is human?Citation Text: Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: National Academy Press; 1999.
Which was the purpose of the Institute of Medicine IOM report on preventing medication errors?The latest IOM report, Preventing Medication Errors, concludes that medication errors are common and costly. It also lays out an extensive plan for decreasing the frequency of these errors.
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