Impact on Patient Safety

ways that other industries have successfully tackled this problem. It also includes detailed analyses of systems failures in the delivery of care to (primarily) hospitalized patients and identifies steps that healthcare institutions can take to reduce their error rates. The report is essentially a call to action for policymakers, providers, and the American public to create a groundswell for change. The report’s real take-away message is that medical errors are infrequently the result of the lone individual. On the contrary, medical errors are the result of a complex series of system-related problems. In the report’s language, the authors call for the healthcare system to “systematically design safety into processes of care.” Thus, error reduction and improved patient safety focus more on designing systems to reduce the likelihood of error and less on identifying the person or persons responsible for the mistake. This chapter describes the findings in the IOM report and summarizes some of the published literature upon which the findings were based. It also describes publicand privateIn October 1999, the Institute of Medicine (IOM) released To Err Is Human: Building a Safer Health Care System, a report that put the issues of patient safety and medical errors in front of the American public and on the agendas of healthcare institutions, provider associations, consumer groups, the administration, and the Congress seemingly overnight. The national news networks and other media outlets broadcast the startling finding that up to 98,000 people die in hospitals each year as a result of medical errors and countless more are seriously harmed. And, whereas other industries have worked systematically to improve error rates and adverse outcomes over the past several decades, the healthcare industry appears to have made woefully few improvements in patient safety and has essentially maintained high medical error rates over the past 15 years. Despite its shock value and the media attention it received, the IOM report does not include new information about the prevalence of medical errors. It explains the etiology of errors in the healthcare system and describes UNDERSTANDING THE FIRST INSTITUTE OF MEDICINE REPORT AND ITS IMPACT ON PATIENT SAFETY