To Err Is Human: Building a Safer Health System is a
landmark report
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issued in November 1999 by the U.S.
Institute of Medicine
The National Academy of Medicine (NAM), formerly called the Institute of Medicine (IoM) until 2015, is an American nonprofit, non-governmental organization. The National Academy of Medicine is a part of the National Academies of Sciences, E ...
that may have resulted in increased awareness of U.S. medical errors. The push for
patient safety
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of a ...
that followed its release continues. The report was based upon analysis of multiple studies by a variety of organizations and concluded that between 44,000 to 98,000 people die each year as a result of preventable
medical errors
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, i ...
. For comparison, fewer than 50,000 people died of
Alzheimer's disease
Alzheimer's disease (AD) is a neurodegeneration, neurodegenerative disease that usually starts slowly and progressively worsens. It is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in short-term me ...
and 17,000 died of illicit drug use in the same year.
The report called for a comprehensive effort by health care providers, government, consumers, and others. Claiming knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next five years. Though not currently quantified, this ambitious goal has yet to be met.
Impact
The report "brought the issues of medical error and patient safety to the forefront of national concern".
The report has been called "groundbreaking" for suggesting that 2-4% of all deaths in the United States are caused by medical errors.
The report is credited with raising awareness of the extent to which medical error was a problem.
The report described that errors were not rare or isolated, and only by broad planning could they be diminished.
It also described that most errors are systemic in the health care industry, and cannot be resolved at the level of individual health care providers.
Responses
The report had a huge impact on management of health care.
As a result of the report President
Bill Clinton
William Jefferson Clinton ( né Blythe III; born August 19, 1946) is an American politician who served as the 42nd president of the United States from 1993 to 2001. He previously served as governor of Arkansas from 1979 to 1981 and agai ...
signed Senate bill 580, the ''Healthcare Research and Quality Act of 1999'', which renamed The Agency for Health Care Policy and Research to
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ; pronounced "ark" by initiates and often "A-H-R-Q" by the public) is one of twelve agencies within the United States Department of Health and Human Services (HHS). The agency is headquartered i ...
to indicate a change in focus. The bill also funded projects through that organization.
[{{cite web , url= https://www.premierinc.com/safety/topics/patient_safety/index_1.jsp#Responses%20IOM-1%20government , title=Medical errors and the Institute of Medicine (IOM) - Patient safety , work=premierinc.com , year=2014 , accessdate=25 June 2014]
Follow up
The report was followed in 2001 by another widely cited Institute of Medicine report, "
Crossing the Quality Chasm
''Crossing the Quality Chasm: A New Health System for the 21st Century'' is a report on health care quality in the United States published by the Institute of Medicine (IOM) on March 1, 2001. A follow-up to the frequently cited 1999 IOM patient ...
," which furthers many points from the original study. Both are widely referenced. "To Err Is Human" was the inspiration for the
Institute for Healthcare Improvement
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection and analysis, reporting, education, funding, ...
's 100,000 Lives Campaig
which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals.
See also
*
Diagnosis
Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
*
Medical ethics
Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. T ...
*''
How Doctors Think
''How Doctors Think'' is a book released in March 2007 by Jerome Groopman, the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School, chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, and staff wri ...
''
*''
Fatal Care: Survive in the U.S. Health System''
References
External links
On-line access to Institute of Medicine publication"To Err Is Human, Building a Safety Health System" (2000).
Medical literature
1999 documents
Patient safety
Nursing