Accelerate Improvement With Systems Approach and Culture of Safety, Says Expert Panel 15 Years After To Err Is Human
In December 1999, the Institute of Medicine released To Err Is Human: Building a Safer Health System, which launched the patient safety movement and galvanized the public’s attention with its estimate that between 44,000 and 98,000 individuals die each year in the United States from medical errors. At milestone anniversaries since then, the patient safety community has taken stock of its accomplishments and ongoing challenges.
At the 15th anniversary, the National Patient Safety Foundation (NPSF) convened a panel of experts to assess the state of patient safety and set the stage for the next 15 years. The panel was led by co-chairs Donald M. Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) and lecturer in the Department of Health Care Policy at Harvard Medical School, and Kaveh G. Shojania, MD, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of the journal BMJ Quality & Safety.
The report, Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, defines patient safety broadly as a public health problem, acknowledges that some things have improved, and expresses disappointment at the challenges that remain. “The field of patient safety has not achieved enough, despite definite progress having been made,” said Tejal K. Gandhi, MD, MPH, CPPS, president of NPSF.
While patient safety is better understood now than 15 years ago, the report observes that competing interests have drawn attention and resources away from safety efforts. Financial incentives now mean that a small number of specific problems receive attention, sometimes at the expense of overall progress.
Saying, “Patient safety must not be relegated to the backseat” (p. iv), the report calls on organizations to institute a culture of safety and apply a total systems approach to improvement. It issues eight recommendations for achieving total systems safety:
1. Ensure that leaders establish and sustain a safety culture
2. Create centralized and coordinated oversight of patient safety
3. Create a common set of safety metrics that reflect meaningful outcomes
4. Increase funding for research in patient safety and implementation science
5. Address safety across the entire care continuum
6. Support the healthcare workforce
7. Partner with patients and families for the safest care
8. Ensure that technology is safe and optimized to improve patient safety
The report was released in early December 2015, coinciding with the IOM report anniversary and IHI’s Annual National Forum, held in Orlando, Florida. It can be downloaded on the NPSF website. The project was made possible in part through a grant by AIG, which had no influence on the report’s direction or content.
References
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America. Washington, DC: National Academy Press. [Report issued 1999, published 2000].
National Patient Safety Foundation. (2015). Free from harm: Accelerating patient safety improvement fifteen years after To Err Is Human. Retrieved from http://www.npsf.org/?page=freefromharm