To err is human, but errors can be prevented..
Institute of Medicine, 1999
To Err is Human: Building a Safer Health System
As healthcare has become more complex, it has increased the probability that medical errors will occur. According to the landmark 1999 Institute of Medicine (IOM) report, “To Err Is Human,” medical errors are a common occurrence, and some 98,000 deaths each year in the United States are due to human error in the delivery of healthcare. Recent studies, however, suggest that number is much higher—400,000 or more.
Prior to the IOM report, it was recognized that medical errors occurred, but the focus was on ridding the healthcare system of the incompetent care providers who were committing these errors. It was thought that errors could be prevented by simply investigating the events and individuals who cause harm to patients. Few of these investigations, however, focused on the cluster of events that came together in an unfortunate sequence to allow an error to occur.
Since 1999 the focus of medical error prevention has been on systems and how they create an environment that allows these errors to occur. Quality, we have come to learn, can be defined, measured, and improved to provide safer care.