“To Err or Not to Err”
Dr. Jonathan Phillips
In the 2000 report To Err is Human: Building a Safer Health System, the Institute of Medicine first shed a light on patient safety and adverse events in healthcare. This report continues to be cited, even today, by the popular media when discussing the flaws in the U.S. healthcare system. More recent literature has supported the initial findings and has pointed out that Preventable Adverse Events (PAE) contribute at least in part to up to 400,000 annual episodes of harm leading to premature death. [1] However, this important report and subsequent publicity has caused a new sort of science to emerge in healthcare: Quality Improvement (QI) and Patient Safety.
Taking a Look at the To Err is Human Report
The Institute of Medicine (now called the National Academy of Medicine) is a non-profit, non-governmental organization that provides expert opinions with a focus on peer-reviewed publications. [2] In the above-mentioned report, they were one of the first organizations to define adverse events as a problem, label underlying systemic flaws, define actionable goals, and call for measurable change. By being so often quoted, it fulfills its own goal “to create sufficient pressure to make errors so costly ...that the organization must take action” [3]
To Err set the stage for the progress of the past two decades by defining the problem and providing consistent language for those who would engage in advancing quality and patient safety. Importantly, they drew from the manufacturing industry in recognizing that adverse events are generally not about the actions of an individual, but rather systemic failures that do not protect from doing harm or from harm itself. [3]
In addition to calling for national leadership that has since set and monitored national goals of patient safety, it also was one of the first organizations to call for mandatory disclosures of unintended events, even if there was no patient harm. Instituting voluntary reporting systems has now been integrated into ACGME expectations of Graduate Medical Education as trainees are being taught to critically evaluate the processes of their training institutions. [3]
Finally, the report stopped short of calling for a new regulatory organization: They called for existing stakeholders (i.e. licensing agencies, accreditors, 3rd party payers, and healthcare systems) to demand patient safety progress through the way systems are compensated or achieve their accreditation. As with most change, progress towards these aims is incremental but they are marching forward as payers have begun to closely tie compensation to patient safety and quality metrics. [3]
Patient Safety and Equity
The To Err report has also laid the foundation for the progress that we continue to make. It has provided us with the vocabulary, data, and experiences to now make sure that healthcare is safer and more equitable. However, future quality improvement and safety projects must also focus on achieving equitable outcomes for those patients who have the highest barriers.
Standardization and streamlining of healthcare processes may both lead to and shine the light on healthcare inequities. Recognizing these inequities will require acknowledging their existence to address them concurrently with intentionality. Addressing inequities may often mean that a one-size-fits all approach to patient safety often does not necessarily lead to more equitable care. [4]
Quality Improvement in healthcare has drawn from foundations from other industries. Six Sigma, LEAN, and Kaizen processes have all contributed to the progress that healthcare has made since To Err was published. Organizations such as the Institute for Healthcare Improvement (IHI) have been able to develop robust curriculums for applying quality principles in healthcare.
This has hopefully introduced you to the origins of hospital quality and patient safety. Future blog posts will introduce and contrast varying approaches to QI in healthcare.
Jonathan Phillips, D.O.
University of Louisville | Internal Medicine and Pediatrics
Dr. Jonathan Phillips is PGY-4 resident at the University of Louisville for Internal Medicine and Pediatrics. He attended Kentucky Wesleyan College for his undergrad and completed medical school at the Kanas City University of Medicine and Biosciences.
References
[1] James, John T. PhD A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care, Journal of Patient Safety: September 2013 - Volume 9 - Issue 3 - p 122-128
doi: 10.1097/PTS.0b013e3182948a69
[2] National Academy of Medicine. 2021. About the NAM - National Academy of Medicine. [online] Available at: <https://nam.edu/about-the-nam/> [Accessed 25 June 2021].
[3] Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
[4] Sivashanker K, Gandhi TK. Advancing Safety and Equity Together. The New England journal of medicine. 2020;382(4):301-303. doi:10.1056/NEJMp1911700
