To Err Is Human

To Err Is Human

To Err Is Human is a 1999 report by the Committee on Quality of Health Care in America of the Institute of Medicine that drew national attention to medical errors and patient safety in the United States. The report estimated tens of thousands of annual deaths from preventable adverse events and recommended systems-based reforms involving hospitals, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, and Department of Health and Human Services. Its publication catalyzed policy debates in the United States Congress, responses from professional societies such as the American Medical Association and the American Nurses Association, and initiatives by accreditation bodies like The Joint Commission.

Background and publication

The report was produced by the Committee on Quality of Health Care in America under the aegis of the Institute of Medicine (now the National Academy of Medicine). The committee included experts from institutions such as Johns Hopkins University, Harvard Medical School, Mayo Clinic, Massachusetts General Hospital, and Stanford University School of Medicine. Research methods referenced epidemiologic studies from Harvard School of Public Health, observational work at Brigham and Women's Hospital, and retrospective chart-review projects conducted at Veterans Health Administration. The report synthesized evidence from investigations at the Centers for Disease Control and Prevention, analyses by the Agency for Healthcare Research and Quality, and prior work by the Robert Wood Johnson Foundation and the Commonwealth Fund. Released by the National Academies Press in November 1999, the publication coincided with hearings before the United States Senate and briefings for the White House.

Key findings and recommendations

The report's headline estimate—that tens of thousands of deaths occurred annually from preventable medical errors—drew on studies from Harvard Medical Practice Study, analyses by AHRQ and investigations at the Institute for Healthcare Improvement. It emphasized systems failures observed in settings such as intensive care units at Mayo Clinic and patient safety programs at Brigham and Women's Hospital. Core recommendations urged establishment of a national focus on patient safety via agencies like the Department of Health and Human Services and the Centers for Medicare & Medicaid Services, development of nationwide mandatory and voluntary reporting systems akin to those used by Federal Aviation Administration and National Transportation Safety Board, and adoption of evidence-based practices promoted by organizations such as the World Health Organization and Joint Commission on Accreditation of Healthcare Organizations. The committee recommended investment in information technology exemplified by projects at Brigham and Women's Hospital and Intermountain Healthcare, workforce training initiatives from Institute for Healthcare Improvement, and payment reforms debated in the United States Congress.

Impact on patient safety and healthcare policy

The report catalyzed policy and practice changes across multiple institutions including the Department of Health and Human Services, Centers for Medicare & Medicaid Services, Agency for Healthcare Research and Quality, The Joint Commission, and the Centers for Disease Control and Prevention. It spurred creation of patient safety programs at Veterans Health Administration, adoption of root cause analysis modeled on aviation safety from the Federal Aviation Administration, and the launch of national efforts such as the National Patient Safety Foundation and initiatives by the World Health Organization. Legislative responses in the United States Congress addressed disclosure, reporting, and incentives, while professional societies like the American Medical Association and American Nurses Association revised guidelines. Health systems including Kaiser Permanente, Intermountain Healthcare, and Mayo Clinic implemented electronic health records and medication-safety interventions influenced by demonstrations at Johns Hopkins Hospital and Harvard Medical School. Accrediting bodies including The Joint Commission incorporated new standards for culture change and safety.

Criticisms and controversies

Critics questioned the report's headline mortality estimates and the accuracy of extrapolations from studies such as the Harvard Medical Practice Study and retrospective chart reviews at New York State Department of Health. Some scholars from University of Pennsylvania and Yale School of Medicine argued that methodological limitations and uncertainty in attribution undermined the numerical claims. Professional organizations including the American Hospital Association and associations of physicians raised concerns about unintended consequences of mandatory reporting, potential for malpractice litigation involving the United States Court of Appeals and state judiciaries, and resource burdens on hospitals like County General Hospital-type institutions. Debates involved the roles of disclosure promoted by Institute for Healthcare Improvement versus legal protections advocated by state legislatures and the United States Congress.

Legacy and subsequent developments

The report's legacy includes the emergence of the modern patient safety movement, growth of academic programs at Johns Hopkins Bloomberg School of Public Health, Harvard T.H. Chan School of Public Health, and University of California, San Francisco, and policy evolution within Department of Health and Human Services and Centers for Medicare & Medicaid Services. Follow-up publications by the Institute of Medicine such as Crossing the Quality Chasm and later reports reinforced systems approaches and influenced Affordable Care Act provisions, payment reforms debated in the United States Congress, and quality metrics used by Centers for Medicare & Medicaid Services. Internationally, the report informed World Health Organization patient safety initiatives and national strategies in countries including United Kingdom, Canada, and Australia. Academic literature from New England Journal of Medicine, JAMA, and The Lancet continued to assess error rates, effectiveness of electronic health records pioneered at Intermountain Healthcare and Brigham and Women's Hospital, and safety culture transformations led by organizations such as the Institute for Healthcare Improvement and the National Patient Safety Foundation.

Category:Patient safety Category:Medical ethics Category:Healthcare quality