Five Years After To Err is Human: What Have We Learned? 

Journal of the American Medical Association
May 18, 2005, Vol. 293, Issue #19, pg. 2384-2390.

Review by: Linda Heun, Ph.D. <lheun@aacom.org>

The authors ask about patient safety five years after the Institute of Medicine reported that 98,000 people die annually as a result of medical errors. They conclude that "proven measured fruits" of the IOM reports are few, but it has led to major accomplishments in three areas:

• Framing the way in which professionals think and talk about errors including viewing a) errors of misuse, overuse and underuse as equally important and b) systems change as the most effective method to reduce errors and increase quality.
• Enlisting the support of stakeholders including a) the federal government which launched the academic base for this work, b) accreditation agencies, independent foundations, such as the National Patient Safety Foundation, c) regional coalitions such as the Massachusetts Coalition for the Prevention of Medical Errors, and d) mobilized health care professionals.
• Changing practices through the development of evidence-based safe practices and the implementation of new residency training work hour limitations.

  The authors discuss barriers to measurable improvement in patient safety that are rooted in the culture of autonomous practice, advances in biomedical science, fear and skepticism of practicing professionals, a paucity of measure and lack of leadership at the hospital or health plan level. They also present likely advances in the areas of: use of electronic health records, diffusions of safe practices, training on teamwork and safety, and full disclosure to patients following injury. They urge the Agency for Healthcare Research and Quality to bring together the entities now working separately on these issues to set explicit and ambitious goals for patient safety outcomes by 2010.

  For more information about this article and author(s), visit the Journal of the American Medical Association website.

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