To err is human, but errors can be prevented.
Institute of Medicine [sic], 1999
To Err Is Human: Building A Safer Health System
It has been twenty years since publication of the Institute of Medicine’s landmark report “To Err Is Human,” which brought the serious problem of medical errors into the spotlight for healthcare institutions and their staff members, oversight agencies, and individual consumers of healthcare. Since then a great deal of additional research has taken place or is in process, and a broad range of agencies are working together to foster standardization in data collection, meaningful research, and the creation of effective broad-based tools for addressing all the different categories of medical errors.
Coming to understand that medical errors are seldom the responsibility of one isolated “bad” employee who can be terminated, we have learned to focus on the clusters of events that come together in an unfortunate sequence to allow an error to occur—a system approach. That approach has allowed us to better understand the causes of errors and to create effective training and tools to reduce and, ultimately, eliminate medical errors.
Success stories like the Tampa General Hospital emergency department’s reducing CAUTI’s by 75% can inspire and encourage others. Utilizing a program that had support and participation that started at the top with ED leadership and included other departments and a variety of staff members utilizing tools developed by AHRQ resulted in a significant improvement in patient safety and increased skill and morale among staff (AHRQ, 2018e).
The AHRQ just released in late January 2019 preliminary data indicating that for the period 2014–2017 there was an overall 13% decline in hospital-acquired conditions (HACs). HACs include the medical errors discussed in this course, along with obstetric adverse events and a few other conditions. AHRQ notes that this decline meant that 20,500 deaths were prevented and $7.7 billion in related medical costs were saved in the time between 2014 and 2017 (AHRQ, 2019d,e). An infographic that presents HACs vividly is available here; it is too large to fit the parameters of this course.
There is still plenty to be done to save even more lives and more money but this is encouraging news.
Florida Agency for Healthcare Administration (AHCA)
Office of Risk Management & Patient Safety
Institute for Safe Medicine Practices (ISMP)
A non-profit organization devoted entirely to medication errors and safe medication use. The Institute “collects and analyzes reports of medication hazardous conditions, near-misses, errors, and other adverse events.” ISMP also “disseminates timely medication safety information, risk reduction tools, and error-prevention strategies.”