16 hours ago · N Engl J Med. 2002; 342(15):1123-1125. In this article, Brennan describes how the Institute of Medicine (IOM) report To Err is Human may, in fact, be harmful. The author offers an important perspective, as he was an investigator in two of the studies used to draw conclusions in the report. He expresses concerns about the extrapolation of these data and suggests that the … >> Go To The Portal
The 5 year anniversary of the IOM report has sparked debate regarding its impact on patient safety and quality of health care. 8 Critics of the report have suggested that, although safety is a vital component of healthcare quality, the report may have done more harm than good. 8,9 They contend that, by focusing undue attention on accidental deaths which are difficult to study and prevent, limited resources are being drawn away from other important quality improvement initiatives. 8,10 Conversely, patient safety advocates argue that the IOM report has galvanized the public and the healthcare industry into making necessary changes and we are beginning to see the first signs of progress. 4,5,11,12 However, objective assessment of the impact of the IOM report has been difficult as no comprehensive nationwide monitoring system exists for patient safety.
The IOM in a report revealed that more than one million Afghan citizens have been deported or forced to return to Afghanistan in 2021, with more than thousands fleeing the country in quest of a better quality of life. IOM Afghanistan has also created a ...
PHILADELPHIA, Dec. 9, 2021 /PRNewswire/ -- ObservSMART, a patient safety compliance system, announced today that Day Kimball Hospital in Putnam, Connecticut, has begun using its technology to ...
Patient Harm - Harm to a patient as a result of medical care or in a health care setting, including the failure to provide needed care. Patient harm refers collectively to adverse events and temporary harm events.
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.
On November 29, 1999, the Institute of Medicine (IOM) released a report called To Err is Human: Building a Safer Health System. The IOM released the report before the intended date because it had been leaked, and one of the major news networks was planning to run a story on the evening news.
To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care.
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.
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.
In their report entitled “The Future of Nursing: Leading Change, Advancing Health,” IOM envisions a future where “primary care and prevention are central drivers of the health care system, interprofessional collaboration and coordination are the norm, and payment for health care services rewards value, not volume of ...
A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility.
Definition of to err is human formal. : it is normal for people to make mistakes.
Alexander Pope, poet of the Enlightenment, lent a famous line from his 1711 treatise An Essay on Criticism to the US Institutes of Medicine's report on patient safety: To Err is Human.
To achieve a better safety record, the report recommends a four-tiered approach: Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety.
To err is human, to forgive divine often praises those who forgive others under difficult circumstances, or it urges forgiveness from people holding onto their anger. Bad and unacceptable things happen in life.
The report, called "Improving Diagnosis in Health Care," asserts that diagnostic errors occur daily in every health care setting nationwide, yet they have never been adequately studied. No one knows how many people suffer from misdiagnoses or delays that affect their care.
Clumsy health information technology, including electronic medical records, also represents a "barrier to good health care," Ball says, because information isn't easily accessible and is often presented in a confusing manner.
Diagnostic errors are the principle cause of paid malpractice claims and are almost twice as likely to end in a patient's death than claims for other medical mishaps. They also represent the biggest share of total payments.
One vital check on the accuracy of a diagnosis is following up with the patient, a cycle that promotes better care and reinforces learning, says Dr. Donald Berwick, president emeritus and senior fellow at the Institute of Healthcare Improvement. "The diagnosis is the hypothesis, the treatment is a test. If we don't know what happened to the patient it's difficult to improve either our diagnosis or treatment."
Postmortem research suggests that diagnostic errors are implicated in one of every 10 patient deaths. Not every death is scrutinized, however, so the findings can't be generalized to all hospital patients.
Evidence is incomplete, but still shows most patients will be impacted by the problem at some point in their lives.
There is no easy fix, the report concludes. What's required is a major reassessment of the diagnostic process and a commitment to change. It must begin with a common definition of what constitutes a diagnostic error--and the data to figure out possible remedies and measure progress.
Patient safety has progressed from being the subject of occasional publications to being the focus of dedicated issues17and series18,19in prominent medical journals. Secondly, the IOM report has changed the very nature of the patient safety conversation from focusing on dispensing blame to improving systems. Efforts to promote patient safety originated from studies in the 1990s designed to understand medical malpractice rather than improve health care. The IOM report introduced the concept of preventable injury secondary to systems issues. A paradigm shift is underway. Thirdly, patient safety is a new field and both time and stable funding are needed for meaningful research to develop. Many of the largest patient safety studies were published before the IOM report.20,21,22There has been a limited increase in the number of research publications. However, a distinct change in the methodology of these publications has already emerged with a new emphasis on interventions to improve patient safety. In addition, health sciences researchers are increasingly collaborating with scientists from fields of human factors engineering, psychology, and informatics creating prospects for innovative approaches to longstanding safety challenges. However, for these gains to be sustained, ongoing federal funding at present or higher levels will be needed. The level of patient safety funding in future AHRQ budgets is uncertain.
The 5 year anniversary of the IOM report has sparked debate regarding its impact on patient safety and quality of health care.8Critics of the report have suggested that, although safety is a vital component of healthcare quality, the report may have done more harm than good.8,9They contend that, by focusing undue attention on accidental deaths which are difficult to study and prevent, limited resources are being drawn away from other important quality improvement initiatives.8,10Conversely, patient safety advocates argue that the IOM report has galvanized the public and the healthcare industry into making necessary changes and we are beginning to see the first signs of progress.4,5,11,12However, objective assessment of the impact of the IOM report has been difficult as no comprehensive nationwide monitoring system exists for patient safety.
A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. 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. Publications of original research increased from an average of 24 to 41 articles per 100 000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100 000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v2%, p<0.001) while organizational culture was the most frequent subject (1% v5%, p<0.001) after publication of the report.
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.
Publications were aggregated into 3 month intervals and data analysis was limited to the 5 year periods before (1 November 1994 to 1 November 1999) and after (1 November 1999 to 1 November 2004) the 1 November 1999 release of the IOM report. Patient safety research awards were analyzed in yearly intervals to coincide with funding decisions for each fiscal year (1 October to 30 September). Data analysis was limited to the five fiscal year periods before (1995–1999) and after (2000–2004) the release of the IOM report.
The literature search identified 12 429 articles from among 5 207 194 MEDLINE publications between 1 January 1994 and 1 January 2005. Thirteen duplicates were identified leaving 12 416 publications for review. Patient safety or medical errors were identified as the principal focus for 5905 publications (48%). Six articles were excluded because the date of publication could not be identified. Among the remaining articles, 5514 were published between 1 November 1994 and 1 November 2004 in 1095 journals from 40 countries and were included in the principal analyses. The search of the CRISP database identified 1745 awards out of 732 826 federally funded research awards granted for the fiscal years 1995–2004. Patient safety or medical errors were identified as the principal focus for 567 (32%) of the research awards. Agreement on the classification of publications and research awards was good: principal publication focus on patient safety or medical errors (agreement 86%, κ = 0.71), publication type (agreement 74%, κ = 0.67), publication subject (agreement 60%, κ = 0.57), methodology of reports of original research (agreement 68%, κ = 0.58), and principal research award focus on patient safety or medical errors (agreement 90%, κ = 0.77).
The new IOM report emphasized that patients need to take more responsibility for their own medication education and self-management. The American College of Emergency Physicians provides medical forms to consumers to pass along information to emergency physicians in case of an emergency.
Bootman noted that the report raised awareness because it alerted the public and physicians to the magnitude of the problem. He said some hospital administrators subsequently hired medical safety officers, and many physicians took a hard look at their internal processes of prescribing and dispensing drugs to their patients.
The IOM committee made seven recommendations to reduce medication errors: 1 ▪ Patients need more information and education designed to strengthen medication self-management, and they should maintain an up-to-date list of every drug they take, including non-prescription drugs. 2 ▪ Government agencies should enhance the resource base for consumer-oriented drug information and medication self-management. 3 ▪ All health care systems should immediately make complete patient-information and decision-support tools available to physicians and patients. These systems should capture information on medication safety and use the data to improve the safety of their health care delivery systems. Part of this improvement should include formulating a plan to write prescriptions electronically by 2008 and implementing that plan by 2010. 4 ▪ Government agencies, the Institute for Safe Medication Practices, and the U.S. Pharmacopeia should collaborate to improve the labeling and information inserts for drugs, including free samples. 5 ▪ Industry and government agencies should collaborate to establish standards for a common drug nomenclature to be used in drug databases in all clinical information technology systems based on standards for the national health information infrastructure. 6 ▪ Congress should allocate the necessary funding and the Agency for Healthcare Research and Quality should mount broad research on the safe and appropriate use of medications across all care settings. 7 ▪ Oversight and regulatory organizations and payers should use all available channels, including legislation and accreditation, to motivate the adoption of practices and technologies that have been shown to reduce medication errors. (See box .)
Pace, also the director of the National Research Network of the American Academy of Family Physicians, said EDs are at risk for medication errors because of high turnover and lack of knowledge about many patients who come through the doors. Physicians in EDs “know almost nothing about the patients,” noted Dr. Pace.
Dr. Pace, also the director of the National Research Network of the American Academy of Family Physicians, said EDs are at risk for medication errors because of high turnover and lack of knowledge about many patients who come through the doors.
Every year, at least 1.5 million Americans sustain harm because of medication errors, according to a new report from the Institute of Medicine released at a news briefing in Washington, D.C. Members of the IOM committee who prepared the report estimated that the extra medical costs of treating medication errors that occur in hospitals alone mount to at least $3.5 billion annually. This figure, which the committee said might be an underestimate, does not take into account the indirect costs of such errors, including lost wages, loss of productivity, emotional stress and suffering, and additional health care costs.
The IOM committee made seven recommendations to reduce medication errors:
Setting a Direction. In early 2000, just 60 days after the IOM report was published, the Federal Government, through an AHRQ-led task force, released Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.
To build a robust patient safety infrastructure, the Agency began its work to gain a better understanding of the systemic factors that combine in unanticipated ways and threaten patient safety. Researchers studied the best ways to identify and report on these factors and examined the impact that working conditions, health care information technology, and enhanced provider expertise could have on addressing patient safety challenges.
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.
The Agency's official designation as the Federal lead in patient safety began when the Healthcare Research and Quality Act of 1999 was signed into law. It required AHRQ to "conduct and support research and build private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury in health care delivery; (2) develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety; and (3) disseminate such effective strategies throughout the health care industry."
The IOM noted that many of the errors in health care result from a culture and system that is fragmented, and that improving health care needs to be a team sport. Research indicated that mistakes were not due to clinicians not trying hard enough; they resulted from inherent shortcomings in the health care system. Today, while progress has been made, it has not spread evenly throughout the Nation's health care system.
As suspected, the 100+-hour workweek—a traditional rite of passage for young physicians—was found to increase medical errors . AHRQ-funded studies found that medical interns continued to work shifts that exceeded the 80-hour workweek limit set by the Accreditation Council for Graduate Medical Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries. Studies also found that after working extended shifts, medical interns doubled their risk of car crashes when driving home from the hospital. A toolkit, " Implementing Reduced Work Hours to Improve Patient Safety ", was developed to help address some of the patient safety issues related to extended work hours.
Once published, the report was immediately used by providers as well as the National Quality Forum (NQF), a public-private partnership established as a voluntary consensus standards-setting organization, as it set about publishing and updating a set of endorsed patient safety practices.
Principal subject of patient safety publications before and after publication of the IOM report “ To Err is Human ”.
The 5 year anniversary of the IOM report has sparked debate regarding its impact on patient safety and quality of health care. 8 Critics of the report have suggested that, although safety is a vital component of healthcare quality, the report may have done more harm than good. 8,9 They contend that, by focusing undue attention on accidental deaths which are difficult to study and prevent, limited resources are being drawn away from other important quality improvement initiatives. 8,10 Conversely, patient safety advocates argue that the IOM report has galvanized the public and the healthcare industry into making necessary changes and we are beginning to see the first signs of progress. 4,5,11,12 However, objective assessment of the impact of the IOM report has been difficult as no comprehensive nationwide monitoring system exists for patient safety.
The literature search identified 12 429 articles from among 5 207 194 MEDLINE publications between 1 January 1994 and 1 January 2005. Thirteen duplicates were identified leaving 12 416 publications for review. Patient safety or medical errors were identified as the principal focus for 5905 publications (48%). Six articles were excluded because the date of publication could not be identified. Among the remaining articles, 5514 were published between 1 November 1994 and 1 November 2004 in 1095 journals from 40 countries and were included in the principal analyses. The search of the CRISP database identified 1745 awards out of 732 826 federally funded research awards granted for the fiscal years 1995–2004. Patient safety or medical errors were identified as the principal focus for 567 (32%) of the research awards. Agreement on the classification of publications and research awards was good: principal publication focus on patient safety or medical errors (agreement 86%, κ = 0.71), publication type (agreement 74%, κ = 0.67), publication subject (agreement 60%, κ = 0.57), methodology of reports of original research (agreement 68%, κ = 0.58), and principal research award focus on patient safety or medical errors (agreement 90%, κ = 0.77).
Conclusions: 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.
“ To Err is Human ” has provided a window of opportunity for improving patient safety in health care.
Background: The “ To Err is Human ” report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards.
Methods: We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995–2004.
The first report completed by the IOM Committee on Quality of Health Care in America was released in November 1999, and it focused on medical errors. Titled To Err Is Human: Building a Safer Health System, the report established a baseline of information on the current state of the system and made a shocking yet convincing case for high levels of concern for the safety of patients seeking care within that system. Focused primarily on medical errors, the report presented these errors as a serious health threat, one that could be compared with the lethality of breast cancer, motor vehicle accidents, and acquired immunodeficiency syndrome. The report asserted that the old systems of quality care were unreliable, and that varied hit- or-miss attempts to fix the broken portions of the system were simply not enough to correct the overall problem – an overhaul of the health care system itself was called for (Shaw, Elliott, Isaacson, & Murphy, 2007).
The hospitals would be the first facilities required to report, with mandatory reporting then phased in over time for all other types of health care organizations. It was hoped that a mandatory reporting system would guarantee that patient injuries and patient deaths would not be taken lightly or go unexamined.
Additionally, health care organizations would be motivated via incentives to create and put internal safety systems into practice to lessen the possibility of medical errors, as well as to respond to the larger public's desire for more information about patient safety and prevention practices used to minimize medical errors.
The Committee on Quality of Health Care in America concluded that it was not acceptable for patients to be harmed in any way by the system of medical care intended to provide healing in time of illness and comfort to the sick, especially given that American health care was expected to be premised on the concept that a provider should “first, do no harm" (translating the Latin phrase primum non nocere). After spotlighting the appalling number of medical errors, the committee went on to present a comprehensive four-tiered strategy (outlined below) for government agencies, health care providers, and health care industry stakeholders, as well as patients themselves, to come together to reduce preventable medical errors. The report concluded that many methods of prevention for these errors already existed but were not being used consistently (IOM, 1999).
This 1999 IOM report found that at least 44,000 Americans, and possibly as many as 98,000, die each year in hospitals because of serious medical errors that could have been prevented. In addition to the patients who lose their lives, this report documented how tens of thousands of patients “suffer or barely escape from nonfatal injuries that a truly high- quality care system would largely prevent” (p. 2). As a clinician myself I believe that although these numbers were indeed alarming, they barely began to evaluate the true situation. The errors that were tracked and analyzed in this report were mostly those that occurred in the hospital setting; the report did not account for errors that occurred in the many ambulatory care settings that provide the majority of health care services to Americans.
Suggestions were also aimed at those who educate health care professionals, because attention to safety must be an innate part of the training and education process. Professional societies were encouraged to step up and support this movement by leading the way in demanding improvements in safety. Professional societies could accomplish this through the development and publication of their own performance standards for their members, by providing educational sessions and other communications about safety practices, and by sponsoring and encouraging interprofessional collaboration on safety enhancement research and efforts.
Hit-or-miss mentions and efforts are no longer good enough; safety must now be stated as an explicit goal of each health care organization, and firmly backed by strong leadership from the managers, the care providers, and the governing bodies that help to regulate the provision of care services.
Just a few years after To Err Is Human, the Joint Commission leveraged its role as an accrediting body to identify required steps for preventing medical errors. The National Patient Safety Goals program released its first list of standards in 2003 and continues to update them annually.
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. Just 60 days after To Err Is Human was published, AHRQ released Doing What Counts for Patient Safety, which outlined several specific strategies to curb medical errors.
The AAMC promotes quality and safety. In 2008, the AAMC created the Integrating Quality Initiative to help its member medical schools and teaching hospitals achieve safe, high-quality, and high-value care rooted in continuous quality improvement and implemented through interprofessional education and practice.
The WHO and a team from the Harvard T.H. Chan School of Public Health led by safety expert Atul Gawande, MD, also developed a Surgical Safety Checklist. The list, available in 19 languages, reminds practitioners to confirm such key pieces of information as the patient’s name, procedure, and incision site. After implementation of the checklist, participating hospitals’ death rate dropped by nearly half, a 2009 study published in the New England Journal of Medicine reported.
Today, patient harm from medical errors is no longer considered inevitable, notes Peter Pronovost, MD, PhD, a safety expert and the chief clinical transformation officer at University Hospitals in Ohio. “What really changed was the narrative we told” about medicine’s ability to avoid safety problems, he says. “It’s both hopeful and humbling where we’ve been.”