institute of medicine report on patient medical safety

On November 29, 1999, the Institute of Medicine (IOM) released its comprehensive report on medical error and patient safety in America, To Err is Human: Building a Safer Health System. 1 This 287-page report outlines the current state of affairs in the United States with respect to medical error and patient safety, and enumerates broad and specific steps that can be taken to improve patient safety and reduce medical error in the United States.

Full Answer

Is the Institute of Medicine doing enough to improve patient safety?

While the Institute of Medicine made recommendations to Congress for investigating medical errors and improving patient safety, the reality was that extensive foundation building needed to occur before meaningful improvements could be put into action.

How many patient safety articles are published after the IOM report?

The rate of patient safety publications increased from 59 to 164 articles per 100 000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles.

What is the National Summit on medical errors and patient safety?

Later in 2000, under AHRQ leadership, that task force held a National Summit on Medical Errors and Patient Safety. The meeting focused on multistakeholder collaboration and input to be used by AHRQ in setting its patient safety research agenda.

Does the “To Err is human” report improve patient safety?

Publication of the report “To Err is Human” was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.

How do the Institute of Medicine reports influence patient safety?

The IOM report called for a 50% reduction in medical errors over 5 years. Its goal was to break the cycle of inaction regarding medical errors by advocating a comprehensive approach to improving patient safety. This IOM report received tremendous attention from both the public and the healthcare industry.

What overall message was stated by the Institute of Medicine report To Err is Human?

The message in To Err is Human was that preventing death and injury from medical errors requires dramatic, systemwide changes.

What did the IOM report To Err is Human find as contributors to medical errors?

The Institute of Medicine (IOM) released their landmark report, To Err Is Human, in 1999 and reported that as many as 98,000 people die in hospitals every year as a result of preventable medical errors.

What is the 2000 IOM report?

Tracking The Changing Safety Net The 2000 IOM report found that the federal government lacked any comprehensive, coordinated ability to track and monitor the changing status of America's health care safety net and its success in meeting the needs of our most vulnerable populations.

Has patient safety improved since To Err is Human?

By heeding the report's advice, the healthcare industry has seen vast improvements, with patient safety metrics improving significantly over the past 20 years.

What has been the historical importance of the Institute of Medicine IOM reports since 1999?

What has been the historical importance of the Institute of Medicine (IOM) reports since 1999? 1. They stimulated the development of strategies that will improve quality of care.

Which quality issues were found in the Institute of Medicine IOM study To Err is Human: Building a Safer Health System?

Which quality issues were found in the Institute of Medicine (IOM) study, To Err is Human: Building a Safer Health System? Many errors are preventable. Data from the IOM study concluded that up to 98,000 patients die each year from preventable medical errors.

What was the focus of the 1999 Institute of Medicine report To Err Is Human?

To Err Is Human: Building a Safer Health System is a landmark report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors.

What was the title of the Institute of Medicine IOM report that brought the issue of deaths from medical errors in the United States to the forefront?

Abstract. The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system.

What is the Institute of Medicine report?

Released in October 2010, the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, is a thorough examination of the nursing workforce.

What percentage of medical errors are preventable?

Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6).

What are the elements of the triple aim?

​What Is the Triple Aim?Improving the patient experience of care (including quality and satisfaction);Improving the health of populations; and.Reducing the per capita cost of health care.

Why is a new health care delivery system needed?

To achieve this, a new health care delivery system is needed — a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to ...

What is the new standard for care?

Patient Safety: Achieving a New Standard for Care. Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed — a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all ...

Should Americans be able to count on receiving health care that is safe?

Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed — a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholde ….

What is the AHRQ tool?

To help organizations understand and quantify patient safety events and areas of vulnerability in their institutions, AHRQ developed a useful measuring and monitoring tool: the Patient Safety Indicators (PSIs). The tool includes 20 hospital-level and 7 regional measures. By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli, accidental punctures and lacerations, and many other departures from safe care that are preventable. AHRQ continues to make the PSIs available as a free software program and uses PSIs regularly in its annual National Healthcare Quality Report and National Healthcare Disparities Report.

What is AHRQ Advances in Patient Safety?

AHRQ released Advances in Patient Safety: From Research to Implementation as a way to share the progress occurring in the first half of the decade. The four-volume publication, comprising 140 articles, sought to bridge the gap between the research underway and its integration into practice. The compendium covered a wide range of research paradigms, clinical settings, patient populations, reporting systems, measurement and taxonomy issues, tools and technology, implementation challenges, safety culture, and organizational considerations. The volumes helped fuel efforts to improve patient safety and provided a measure of progress. More importantly, they also provided a sense of remaining challenges.

What is AHRQ WebM&M?

AHRQ WebM&M serves as a free, online journal and forum for the examination of a variety of patient safety and quality issues. It features analysis of medical error cases by recognized experts and provides interactive learning modules for health care professionals, clinicians, administrators, patient safety officers, and trainees. Since its launch, AHRQ WebM&M has grown in popularity and continues to be one of AHRQ's most frequently visited Web sites.

What is AHRQ grant?

AHRQ 's initial grants helped build a patient safety knowledge base and informed the Agency's thinking about the next steps it needed to take. As the knowledge base continued to evolve, it became clear that AHRQ needed to produce sound research studies and to ensure that the information, educational content, new approaches, and tools it provided were relevant to providers as they initiated their own patient safety improvement efforts. What follows is a brief description of some of the projects that were carefully designed, developed, and evaluated.

What is a PSIC?

In response to the need to expand the patient safety knowledge and skills of midlevel professionals responsible for investigating medical errors and initiating improvements, AHRQ partnered with the Department of Veterans Affairs' National Center for Patient Safety and began the first of four 9-mont h Patient Safety Improvement Corps (PSIC) training programs. Participants received training on tools and topics including analyzing root causes, analyzing health care failure modes and effects, applying human factors principles, assessing patient safety culture, and making a business case for patient safety. By the program's end, teams had been trained in every State, as well as the District of Columbia and Puerto Rico. Feedback the Agency received that PSIC graduates were, in turn, training their own personnel in patient safety principles acquired from the program provided evidence that this program represented a significant step in disseminating patient safety knowledge throughout the country.

What is the most common complication of hospital care?

Data indicate that health care-associated infections (HAIs) are the most common serious complication of hospital care, striking nearly 2 million U.S. hospital patients, resulting in an estimated 99,000 deaths, and costing the health care system up to $20 billion each year, according to the Centers for Disease Control and Prevention (CDC). The most common HAI is methicillin-resistant Staphylococcus aureus (MRSA). With some MRSA-related projects already underway, Congress directed AHRQ to work with its Federal partners at the CDC and the Centers for Medicare & Medicaid Services to develop an action plan to identify and help reduce the spread of MRSA and related HAIs. The action plan is designed to:

What is the Patient Safety and Quality Handbook?

Given the central role that nurses serve in patient care and the likelihood that they are among the first health care professionals to recognize errors and prevent harm to patients, the Agency teamed with the Robert Wood Johnson Foundation to develop and distribute a handbook for nurses entitled Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Even though working conditions may be less than optimal and the needs of patients are quite diverse, the opportunities for patient safety and quality improvement are clearly addressed. More than 22,000 copies of the three-volume handbook have been distributed to nursing schools and clinicians in the field.