To Err Is Human Re-emphasizing the Message of Patient Safety

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,

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. Media throughout the country recognized this opportunity for a headline story describing a very large number of hospital deaths from medical errors —possibly as great as 98,000 per year. The problem in other care settings was unknown, but suspected to be great.

The search was on to find out who was to blame and how to fix the problem. Congressional hearings were subsequently held. Governmental agencies, professional groups, accrediting organizations, insurers, and others quickly responded with plans to define events and develop reporting systems. Health care organizations were put on the defensive. Recognizing that individual accountability is necessary for the small proportion of health professionals whose behavior is unacceptable, reckless, or criminal, the public held organizational leadership, boards, and staff accountable for unsafe conditions. Yet imposing reporting requirements and holding people or organizations accountable do not, by themselves, make systems safer.

What was often lost in the media attention to hospital deaths from medical errors cited by To Err is Human was the original intent of the IOM Committee on Quality Health Care in America, which developed the report. That committee believed it could not address the overall quality of care without first addressing a key, but almost unrecognized component of quality; which was patient safety. The committee’s approach was to emphasize that “error” that resulted in patient harm was not a property of health care professionals’ competence, good intentions, or hard work. Rather, the safety of care—defined as “freedom from accidental injury”—is a property of a system of care, whether a hospital, primary care clinic, nursing home, retail pharmacy, or home care, in which specific attention is given to ensuring that well-designed processes of care prevent, recognize, and quickly recover from errors so that patients are not harmed.

This chapter focuses on the principles described in the IOM report, many of which can be mapped to what are now called safe practices and all of which are valuable guides. This chapter is not intended to address the growing body of evidence; rather, the chapter summarizes the starting point—the IOM recommendations based on the literature and the knowledge of the committee members who developed the report.

Moving the Focus From Errors to Safety

Errors occur in health care as well as every other very complex system that involves human beings. The message in To Err is Human was that preventing death and injury from medical errors requires dramatic, systemwide changes. Among three important strategies—preventing, recognizing, and mitigating harm from error—the first strategy (recognizing and implementing actions to prevent error) has the greatest potential effect, just as in preventive public health efforts.

Improving Safety by Understanding Error

Every day, physicians, advance practice nurses, nurses, pharmacists, and other hospital personnel recognize and correct errors and usually prevent harm. Errors, defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” do not all result in injury or harm. Errors that do cause injury or harm are sometimes called preventable adverse events—that is, the injury is thought to be due to a medical intervention, not the underlying condition of the patient. Errors that result in serious injury or death, considered “sentinel events” by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]),signal the need for an immediate response, analysis to identify all factors contributing to the error, and reporting to the appropriate individuals and organizations to guide system improvements.