December 1, 2009: The Patient Safety Field Turns Ten

On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had barely moved the needle of public and professional attention.

IOM Report coverThe IOM Report succeeded beyond its framers’ wildest dreams, and the movement they spawned turns ten today. Please indulge me while I spend a nostalgic moment recalling the remarkable spin that launched the patient safety field. I’ll then segue to a summary of my assessment of what we’ve accomplished over the past decade (I outline this more fully in an article in today’s web version of Health Affairs, which I hope you’ll take a look at).

In Internal Bleeding, after describing the history of the IOM (founded in 1970 as the National Academy of Science’s think tank for healthcare issues) and the fact that the venerable organization was not exactly known for its eye-popping PR, Kaveh Shojania and I wrote:



So one could not help but be taken aback by the screaming headlines that leapt off the book jacket of the [IOM Report]. One part Constitution Avenue to three parts Madison Avenue, its tone instantly caught the attention of the general populace and the media. Just consider the breathless prose of the book jacket, more like the trailer for a Hollywood blockbuster than the synopsis of an academic report:

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That’s more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention…. This volume reveals the often-startling truth of medical error and the disparity between the incidence of error and public perception of it…

As if that wasn’t enough pizazz, the authors converted the staggeringly large but potentially bloodless “44,000-98,000 deaths per year” figure into the now-famous “Jumbo Jet Units” – making the point that the number of deaths from medical mistakes was the equivalent of a large plane crashing every day.

Although some have critiqued the “crash-a-day” spin as hyperbolic, I continue to believe it was masterful. Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it. (And just consider what our response would be if, in fact, a commercial airliner crashed for “just” two or three days in a row!) The IOM Report received saturation media coverage for several days, after which more than 50% of Americans surveyed were familiar with the epidemic of medical errors. In one bold stroke, medical mistakes joined airline and food safety (and, two years later, terrorism) as enduring sources of angst in the American zeitgeist.

While there are many metrics of the IOM Report’s impact, my favorite is this: even today, one can say “The IOM Report” and most folks will understand the reference to To Err is Human. This, despite the fact that the IOM has published 526 reports since To Err is Human. Want more: a Google search on “Institute of Medicine Report” pulls up the IOM’s website as the first hit; To Err is the second.

That’s all well and good, but what have we actually accomplished? In today’s Health Affairs article, I present my view of the progress we’ve made in the patient safety field’s first decade. I give us an overall grade of B-, a slight increase from the C+ I awarded 5 years ago in a similar Health Affairs paper.

In writing today’s article, I was struck by the emergence of state reporting systems, centered around the National Quality Forum’s list of “never events,” as the key maneuver that got safety reporting off the ground, and the increased safety activity within hospitals (many of which now have fairly effective patient safety enterprises) and national organizations (such as the NQF and AHRQ). On the other hand, it is remarkable how little progress we’ve made in IT (particularly when you contrast it with the breathtaking progress we’ve made in IT in virtually every other part of our personal and professional lives), and how we’re just beginning to grapple with balancing “no blame” and accountability. And, as I feared, regulators and accreditors are facing increasing challenges, as the low-hanging fruit (such as abolishing high-risk abbreviations) has been picked, leaving them struggling to improve performance in highly complex, nuanced areas like safety culture, medication reconciliation, and addressing problems caused by disruptive caregivers.

Many people will look at the past 10 years and wonder whether we’ve accomplished much of anything. I sympathize with this concern, one that’s partly driven by our maddeningly limited ability to measure progress in safety. Yet as I wander around my own medical center, signs of progress are unmistakable. Our safety enterprise is much more vigorous than it was five years ago (it was nonexistent 10 years ago). Despite some major IT snafus, we are using an electronic health record, and it is a far better way of communicating information than via snippets of chicken scratch penned on dead trees. During a weekly two-hour meeting, we analyze serious errors and review progress in fixing the unsafe conditions we uncover. Our residents and students are (mostly enthusiastically) participating in new safety and quality curricula. We are measuring safety outcomes such as healthcare-associated infections and reporting these results regularly at the highest levels of the organization. All good stuff.



Yes, there is much more for us to do. Patients everywhere are still harmed by preventable infections, falls, communication glitches, wrong-site surgery, medication mix-ups, and more.

But that’s for tomorrow. Today, let’s also take a moment to celebrate all the good work over the past ten years. In fact, had you asked me on December 1, 1999 how much progress would be possible in the next decade, my guess would have markedly underestimated what we actually have accomplished. As I visit hospitals and healthcare systems around the country, I have been struck by the passion and energy doctors, nurses, pharmacists, and administrators have put into preventing patient harm – driven as much by their moral compass as by the increasingly robust business case for safety.

So, even as we vow to redouble our efforts in the second decade of the patient safety movement (and we must), we should take some pride in the work of the first, work that has unquestionably saved many thousands of lives.

4 Responses to “December 1, 2009: The Patient Safety Field Turns Ten”

  1. sandralpsrn December 2, 2009 at 3:51 am #

    Nice synopsis of the last ten years. I’m glad you give us credit for the strides we have made. One tires of hearing about the lack of progress when I believe we have actually achieved a culture shift. Two years ago when my director presented peer review criteria to the medical board, they were very critical and obstructive. This year, she presented the same criteria as well as additional metrics and they asked for more including behavioral scoring!
    I hope you don’t mean to give the impression that you would like to see only harmful events reported internally. I learn a lot from near miss events, especially multiple similar events. Should we report every single potential event or judge our success based upon number of event reports? Absolutely not, but in my organization we reward “Good Catches” and look for trends to help us to prevent harmful events.

  2. menoalittle December 2, 2009 at 4:24 am #

    Bob,

    Congratulations are the word for your accomplishments. Patient safety and error control programs started years before the To Err report. Errors do occur and do result in sentinel events, but the 98,000 numbers arises from flawed methodology, based on two small studies and extrapolated to the universe. If it had not emanated from the IOM, it would have been ignored. It is surprising, Bob, that you have not debunked the flawed methodology.

    Our friends overseas who report the mother of defect and error cover-ups in the report linked here debunk the little progress made in IT:
    http://www.computerweekly.com/blogs/tony_collins/2009/11/claim-of-censorship-over-cerne.html

    It states, in the report “Homerton told me: ‘We are unable to share documents relating to these meetings as our contract with Cerner includes a confidentiality clause and as such disclosure of the information could give rise to an actionable breach of confidence.’”

    You ask, is HIT ready for its big coming out party? Not until the products are proven to be safe and effective and that after market surveillance is comparable to that for pharma.

    In the meantime, for those desirous of making HIT equipment better and safer, you dost go to the FDA site and report your complaints.

    Best regards,

    Menoalittle

  3. SandralpsRN December 10, 2009 at 1:32 am #

    Bob,

    Saw your Webinar today. Loved hearing your thoughts on the current state of patient safety. I would love to hear what you ultimately do for peer review and more about UCSF’s EMR woes. We too have spent millions of dollars on a system we ultimately do not like and will begin phasing out of that system to Epic which we hope is better, but no system is perfect; nor can one system perform as well in individual areas as Best of Breed systems can.

  4. QualityImprovmentMD December 15, 2009 at 2:43 pm #

    Bob:
    I appreciate the 10 year retropsective pause on the Patient Safety Movement. Why do you think have we not seen a repeat of the Harvard Medical Practice study which was the report that the 98,000 number was extrapolated from?
    We have come so far in these 10 years. At my insitution alone we have 1) insituted a robust incident reporting system that documents over 8000 errors and near misses a year. Many hundreds of changes have resulted from these errors, 2) virtually eliminated most hospital acquired infections such as Ventilator associated pneumonia, surgical site infection and central line blood stream infections, 3) siginficantly lowered our risk adjusted mortality rate through implementing early warning systems, rapid response teams and earlier treatment protocols for sepsis, 4) eliminated inatrogenic Deep Vein throbmosis through improve CPOE decision support, 5) begun “team training” of all our staff to promote collaboration, 6) standardized communication at transitions, 7) made realiaiblity for appropriate care a standard etc etc. This is just at one institution. surely we have reduced the number of errors nationally. This is a journey and there is more to do, yet Isnt it time we repeat the study and change the headlines?

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