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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 ([email protected]).
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.
(Reprinted) JAMA, May 18, 2005—Vol 293, No. 19 2387
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.
(Reprinted) JAMA, May 18, 2005—Vol 293, No. 19 2389
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
1. Kohn KT, Corrigan JM, Donaldson MS. To Err Is
19. Chassin MR, Galvin RW. The urgent need to im-
35. Institute for Healthcare Improvement. Reducing ad-
Human: Building a Safer Health System. Washing- prove health care quality: Institute of Medicine Na- verse drug events: Missouri Baptist Medical Center. Avail- ton, DC: National Academy Press; 1999.
tional Roundtable on Health Care Quality. JAMA.
able at: http://www.ihi.org/IHI/Topics/PatientSafety 2. Joint Commission on Accreditation of Healthcare
/MedicationSystems/ImprovementStories/Reducing Organization. Sentinel event trends: potassium chlo- 20. Heget JR, Bagian JP, Lee CZ, Gosbee JW. John
AdverseDrugEventsMissouriBaptistMedicalCenter ride events by year. Available at: http://www.jcaho M. Eisenberg Patient Safety Awards: system innova- .htm. Accessibility verified April 20, 2005.
.org/accreditedϩorganizations/ambulatoryϩcare tion: Veterans Health Administration National Cen- 36. Samkoff JS, Jacques CH. A review of studies con-
/sentinelϩevents/setϩpotassium.htm. Accessed April ter for Patient Safety. Jt Comm J Qual Improv. 2002; cerning effects of sleep deprivation and fatigue on resi- dents’ performance. Acad Med. 1991;66:687-693.
3. Kelly JJ, Sweigard KW, Shields K, Schneider D. John
21. Kizer KW. Re-engineering the veterans health-
37. Pilcher JJ, Huffcutt AI. Effects of sleep depriva-
M. Eisenberg Patient Safety Awards: safety, effective- care system. In: Ramsaroop P, et al, eds. Advancing tion on performance: a meta-analysis. Sleep. 1996;19: ness, and efficiency: a Web-based virtual anticoagu- Federal Sector Health Care: A Model for Technology lation clinic. Jt Comm J Qual Saf. 2003;29:646-651.
Transfer. New York, NY: Springer-Verlag; 2001.
38. Gaba DM, Howard SK. Fatigue among clinicians
4. Whittington J, Cohen H. OSF Healthcare’s jour-
22. Joint Commission on Accreditation of Health-
and the safety of patients. N Engl J Med. 2002;347: ney in patient safety. Qual Manag Health Care. 2004; care Organizations. Joint Commission announces na- tional patient safety goals. Available at: http://www 39. Harrison Y, Horne JA. The impact of sleep dep-
5. 2004 National Healthcare Quality Report. Rock-
.jcaho.org/newsϩroom/latestϩfromϩjcaho/npsg rivation on decision making: a review. J Exp Psychol ville, Md: Agency for Healthcare Research and Qual- 23. Serious Reportable Events in Patient Safety: A Na-
40. Landrigan C, Rothchild J, Cronin J, et al. Effect of re-
6. Blendon RJ, DesRoches CM, Brodie M, et al. Views
tional Quality Forum Consensus Report. Washing- ducing interns’ work hours on serious medical errors in of practicing physicians and the public on medical ton, DC: National Quality Forum; 2002.
intensive care units. N Engl J Med. 2004;351:1838-1848.
errors. N Engl J Med. 2002;347:1933-1940.
24. Safe Practices for Better Health Care: A Consen-
41. Hospital Governing Boards and Quality of Care:
7. Wolfe S. Bad doctors get a free ride. New York
sus Report. Washington, DC: National Quality Fo- A Call to Responsibility. Washington, DC: National Times. March 3, 2003;sect A:25.
8. Levinson D. New Pennsylvania law requires error
25. Surgical Care Improvement Project. A partner-
42. Agency for Healthcare Research and Quality. Qual-
reporting for learning purposes. Rep Med Guidel Out- ship for better care. Available at: http://www.medqic ity indicators. Available at: http://www.qualityindi- .org/scip. Accessed December 8, 2004.
cators.ahrq.gov. Accessed December 8, 2004.
9. McDonald CJ, Weiner M, Hui SL. Deaths due to
26. National Patient Safety Foundation. Available at:
43. Rozich JD, Haraden CR, Resar RK. Adverse drug
medical errors are exaggerated in Institute of Medi- http://www.npsf.org/. Accessed December 3, 2002.
event trigger tool: a practical methodology for mea- cine report. JAMA. 2000;284:93-94.
27. American Board of Medical Specialties. Status of
suring medication related harm. Qual Saf Health Care.
10. Leape LL. Institute of Medicine medical error fig-
MOC programs. Available at: http://www.abms.org ures are not exaggerated. JAMA. 2000;284:95-97.
/MOC.asp. Accessibility verified April 19, 2005.
44. Leatherman S, Berwick D, Iles D, et al. The busi-
11. Starfield B. Is US health really the best in the world?
28. Bates DW, Teich JM, Lee J, et al. The impact of com-
ness case for quality: case studies and an analysis.
puterized physician order entry on medication error Health Aff (Millwood). 2003;22:17-30.
12. Gurwitz J, Field T, Judge J, et al. The incidence of
prevention. J Am Med Inform Assoc. 1999;6:313-321.
45. Lamb R. Open disclosure: the only approach to
adverse drug events in two large academic long- 29. Bates DW, Gawande AA. Improving safety with
medical error. Qual Saf Health Care. 2004;13:3-5.
term care facilities. Am J Med. 2005;118:251-258.
information technology. N Engl J Med. 2003;348:2526- 46. National Patient Safety Agency. Available at: http:
13. Phillips DP, Christenfeld N, Glynn LM. Increase
//www.npsa.nhs.uk/. Accessed April 22, 2005.
in US medication-error deaths between 1983 and 1993.
30. Leape LL, Cullen DJ, Clapp MD, et al. Pharma-
47. Consumers Advancing Patient Safety (CAPS).
cist participation on physician rounds and adverse drug Available at: http://www.patientsafety.org. Ac- 14. Lazarou J, Pomeranz BH, Corey PN. Incidence of ad-
events in the intensive care unit. JAMA. 1999;282:267- versedrugreactionsinhospitalizedpatients:ameta-analysis 48. Persons United Limiting Substandards and Er-
of prospective studies. JAMA. 1998;279:1200-1205.
31. Kucukarslan SN, Peters M, Mlynarek M, Nafziger
rors (PULSE). Available at: http://www.pulseamerica 15. Healey MA, Shackford SR, Osler TM, Rogers FB,
DA. Pharmacists on rounding teams reduce prevent- Burns E. Complications in surgical patients. Arch Surg.
able adverse drug events in hospital general medi- 49. Kazel R. Minnesota insurer won’t pay hospitals
cine units. Arch Intern Med. 2003;163:2014-2018.
for “never events.” American Medical News. No- 16. Zhan C, Miller M. Excess length of stay, charges,
32. Landro L. The informed patient: hospitals form
vember 8, 2004. Available at: http://www.ama-assn and mortality attributable to medical injuries during “SWAT” teams to avert deaths. Wall Street Journal. .org/amednews/2004/11/08/bisd1108.htm. Acces- hospitalization. JAMA. 2003;290:1868-1874.
17. Centers for Disease Control and Prevention. Moni-
33. Rozich J, Resar R. Medication safety: one orga-
50. Institute for Healthcare Improvement. 100k lives
toring hospital-acquired infections to promote pa- nization’s approach to the challenge. J Clin Out- campaign. Available at: http://www.ihi.org/IHI tient safety—United States, 1990-1999. MMWR Morb /Programs/Campaign/. Accessibility verified April 20, Mortal Wkly Rep. 2000;49:149-153.
34. Rozich J, Howard R, Justeson J, Macken P, Lind-
18. Wenzel R, Edmond M. The impact of hospital-
say M, Resar R. Standardization as a mechanism to 51. Hillman K, Parr M, Flabouris A, et al. Redefining
acquired bloodstream infections. Emerg Infect Dis.
improce safety in health care. Jt Comm J Qual Saf.
in-hospital resuscitation: the concept of the medical emergency team. Resuscitation. 2001;48:105-110.
2390 JAMA, May 18, 2005—Vol 293, No. 19 (Reprinted)
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