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Five Years After To Err Is Human
What Have We Learned?
Five years ago, the Institute of Medicine (IOM) called for a national effort
to make health care safe. Although progress since then has been slow, the
FIVEYEARSAFTERTHEINSTITUTE IOMreporttruly“changedtheconversation”toafocusonchangingsys-
tems, stimulated a broad array of stakeholders to engage in patient safety,
and motivated hospitals to adopt new safe practices. The pace of change is
likely to accelerate, particularly in implementation of electronic health rec-
ords, diffusion of safe practices, team training, and full disclosure to pa-
fort to make health care safe, it is time tients following injury. If directed toward hospitals that actually achieve high
levels of safety, pay for performance could provide additional incentives. But
The IOM’s report, To Err Is Human: improvement of the magnitude envisioned by the IOM requires a national
Building a Safer Health System,1 galva- commitment to strict, ambitious, quantitative, and well-tracked national goals.
The Agency for Healthcare Research and Quality should bring together all
stakeholders, including payers, to agree on a set of explicit and ambitious
tient injuries in health care both in the goals for patient safety to be reached by 2010.
United States and abroad. Patient safety, a topic that had been little understoodand even less discussed in care sys-tems, became a frequent focus for jour- tals, due largely to concerted activities safety, and a recent effort by the Agency physicians.8 The latest surge in the mal- low sensitivity for detecting quality im- ments in safety are widely available.
in dedicated clinics3; and serious infec- Author Affiliations: Department of Health Policy and
Management, Harvard School of Public Health, Bos-
ton (Dr Leape); and the Institute for Healthcare Im- provement, Cambridge, and Department of Pediat-rics, Harvard Medical School, Boston (Dr Berwick), Corresponding Author: Lucian L. Leape, MD, Depart-
ment of Health Policy and Management, HarvardSchool of Public Health, 677 Huntington Ave, Bos- ton, MA 02215 (leape@hsph.harvard.edu).
2384 JAMA, May 18, 2005—Vol 293, No. 19 (Reprinted)
2005 American Medical Association. All rights reserved.
rors and injuries, which is a crucial sci- fied. Importantly, it is much clearer now prove either safety or quality overall is Enlisting the Support of Stakeholders.
the health care industry. Now, it is.
safety research, essentially launching the to be accomplished to realize the IOM’s in error prevention and patient safety be- What Have We Accomplished?
years of support, federal funding for pa- dent in at least 3 important areas: view- ing the task of error prevention, enlist- ity in 3 broad families: overuse (receiv- ward studies of information technology.
As crucial as such technologies are, this Viewing the Task of Error Prevention.
the safety problem, and is quickly starv- about medical errors and injury. It truly doubt that injury and mortality rates are tional reaction. Indeed, the focus on ac- plain the intense public interest in safety alone, most of which are preventable, ac- facilitating the setting of standards. De- use, underuse, and misuse have blurred.
2005 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 18, 2005—Vol 293, No. 19 2385
tion projects, system changes, and train- the constellation of safety practice, with Changing Practices. The third effect
practices, training programs, and the es- gical-site verification.22 Additional prac- der entry systems, proper staffing of in- a major force in increasing awareness.
tion of highly technical surgery services sented in the TABLE.4,28-35 If these results
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2005 American Medical Association. All rights reserved.
Table. Clinical Effectiveness of Safe Practices
Intervention
Surgical site infections decreased by 93%* 66% Reduction of preventable adverse drug events30 78% Reduction of preventable adverse drug events31 Barriers to Progress
95% Reduction in central venous line infections† 92% Reduction in central venous line infections‡ in improving safety in health care is im- pressive. Ten years ago, no one was talk- ing about patient safety. Five years ago, 60% Reduction in adverse drug events over 12 mo (from 7.6 per 64% Reduction in adverse drug events in 20 mo (from 3.8 per Hypoglycemic episodes decreased 63% (from 2.95% of patients 90% Reduction in cardiac surgical wound infections (from 3.9% Out-of-range international normalized ratio decreased by 60% 50% Reduction in adverse outcomes in preterm deliveries|| Adverse drug events reduced by 75% between 2001 and 200335 Ventilator-associated pneumonias decreased by 62%* *J Whittington, written communication, March 2005.
†P. Pronovost, Johns Hopkins Hospital, written communication, January 2005.
‡R. Shannon, written communication, January 2005.
§K. McKinley, Geisinger Clinic, written communication, April 2005.
||B. Sachs, Beth Israel Deaconess Medical Center, written communication, October 2004.
tient care? Why are so many physi-cians still not actively involved in pa-tient safety efforts? What needs to be cal specialties and subspecialties inter- equally large array of allied health pro- tem is, the more chances it has to fail.
practice liability inhibits willingness to dividuals. This culture is technically au- dacious and productive; many of today’s becoming safe, even ultra-safe. The first ity, and it is not surprising that progress in achieving safety in health care is slow.
2005 American Medical Association. All rights reserved.
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mon vision and personally own safety.
What Do We Need to Do?
health care is well poised to increase the ficers and boards of hospitals and health tices faster, and will find increasing in- availability of robust measures. Some ex- ist, such as measures of specific types of infections, certain laboratory tests (blood of a set of patient safety indicators,42 and tice as 2 of the core professional skills ment’s trigger tools for measurement of closure to patients following injury.
finally, an idea whose time has come.
a close. Although actual practice still lags far behind the rhetoric,45 few health care for all complications (B. Sachs, Beth Is- does not increase the risk of being sued, realize that the substantial up-front in- practices that reduce errors, such as an- ticoagulation clinics operated by nurses, ery physician’s office will be paid back tion of the work that needs to be done.
tices will almost certainly accelerate.
ranty claims. In health care, perversely, lutely top strategic priority—fully equal 2388 JAMA, May 18, 2005—Vol 293, No. 19 (Reprinted)
2005 American Medical Association. All rights reserved.
iors, but it seems insufficient to do the to provide incentives for safe care, it re- formance movement is gathering steam.
Setting Safety Goals
Mobilizing Pressure for Change
a significant impact on patient safety in tivity and specificity to accurately iden- would be to set and adhere to strict, am- tify safer care when used in report cards a significant impact on safety, or on re- call for major organizational changes.
zero, or close to zero? These levels have to be in their longer-run self-interest.
2005 American Medical Association. All rights reserved.
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the NQF “never” list.24 In its 100 000 Financial Disclosures: None reported.
ing these results for the patients who de- Funding/Support: This study was supported in part
by the Commonwealth Fund. Dr Leape is the recipi-ent of an Investigator Award from the Robert Wood obstacles lie in beliefs, intentions, cul- Role of the Sponsor: The Commonwealth Fund did
not participate in the design of this report or in the
preparation, review, or approval of the manuscript.
Disclaimer: The views expressed in this article are those
of the authors and do not necessarily reflect the opin-ions of the Commonwealth Fund or its directors, of- REFERENCES
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