Quality Improvement History

To Err Is Human: Building a Safer Health System

In 1999, the IOM published a report  To Err Is Human: Building a Safer Health System. The report found that health care in the United States was not safe. The report stated that as many as “98,000 people die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies”. The report also stated that errors that occurred were the result of a failure to safely complete a task, such as “adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related death, falls, burns, pressure ulcers, and mistaken patient identities”.

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Errors were costly to the organization and left patients feeling unsafe. Patients would see multiple providers, have hospitals stays and surgical procedures, but there was no form of communication between providers or between providers and health care organizations. Contributing to the occurrence of errors was the fact that no one had complete information. Taking everything into account, the IOM came up with four strategies it believed would build a healthier health care system:

· Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety.

· Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.

· Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

· Implementing safety systems in health care organizations to ensure safe practices at the delivery level.

So began the quest for continuous quality improvement. President Bill Clinton’s administration issued executive orders instructing government agencies to conduct or oversee health care programs to implement proven techniques for reducing medical errors and creating a task force to find new strategies for reducing errors. Congress soon launched a series of hearings on patient safety and, in December 2000, it appropriated $50 million to the AHRQ to support a variety of efforts targeted at reducing medical errors.