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Reflecting on To Err is Human: 20 Years of Patient Safety Work

In the years since the IOM published To Err is Human, the industry has turned a critical eye to patient safety.

It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront.

At the time of the 1999 publication, medical errors were killing 98,000 people in the United States every year, the report authors found, outnumbering patient deaths from highway accidents, breast cancer, and AIDS. Deaths from medication errors alone totaled at nearly 7,000 patients annually, exceeding the number of workplace injury deaths, the researchers reported.

And these errors are extraordinarily costly to the medical industry. Repeat tests and procedures used to mitigate previous mistakes rack up high bills, the authors noted, let alone the human costs of medical errors.

“Errors are also costly in terms of loss of trust in the system by patients and diminished satisfaction by both patients and health professionals,” the report authors wrote. “Patients who experience a longer hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health care professionals pay with loss of morale and frustration at not being able to provide the best care possible. Employers and society, in general, pay in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status.”

“Yet silence surrounds this issue,” the authors said.

What came next was an industry-wide movement to address patient safety and a commitment to create a health system in which it was hard for clinicians to make mistakes and easy for them to deliver quality care.

"We believe that with adequate leadership, attention, and resources, improvements can be made," said William Richardson, chair of the committee that wrote the report. "As we say in the report, 'It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead.'"

The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with

“The report authors did a good job of getting people attuned to there's data, a problem, and then there's a solution,” Clapper, who’s an expert in patient safety, reflected on the report’s influence over the years.

“If a solution doesn't exist, then it's not a problem. People thought that nothing could be done about patient safety and that it wasn't a problem. But after the IOM report, people thought that something could be done, so now it was, in fact, a problem.”

The paper called for a national center on patient safety, mandatory and voluntary patient safety reporting, carving out a role for patient and consumer health groups, and, importantly, creating a culture of safety.

Those first few steps focusing on patient safety measures were a good start for addressing safety, Clapper said, but organizations that got stuck only on measurement weren’t able to make the impact that more sophisticated organizations could. The focus on safety culture is where the tide turned.

“Clinicians and the support staff in these organizations think about the safety aspect of patient care and getting them more focused on caring safely,” he explained. “Safety culture starts with an organizational commitment that safety is important and that they will work safely. They'll pay more attention. They'll stay more compliant when something has to do with safety.”

Since the IOM report, many organizations have coalesced around a culture of safety like a North star, calling for zero patient harm as a foundational goal. In these organizations, communication is key, helping to ease the transition of patient handoffs and reducing the risk of a medical complication. Leaders are empowered and accountability is high.

What’s more, critical thinking is of high priority. Hospitals that foster critical thinking skills in staff members across the care continuum, instead of emphasizing specific outcomes measures, tend to see a more successful culture of safety that adheres to the IOM report’s guiding principles.

By heeding the report’s advice, the healthcare industry has seen vast improvements, with patient safety metrics improving significantly over the past 20 years.

Hospital acquired conditions (HACs), for example, have shrunk since the IOM report’s publication, reaching to record low levels in 2017, the most recent year for which the Agency for Healthcare Research and Quality (AHRQ) has data. Between 2014 and 2017, HACs went down by 13 percent, cutting $7.7 billion in costs and saving an estimated 20,500 lives.

These gains build on improvements made in earlier years. Between 2010 and 2014, the nation saw 2.1 million fewer hospital-acquired conditions than in previous years.

Of course, this is not a complete Cinderella story, at least not yet. Patient safety remains a reality at many healthcare organizations, with some still seeing extremely high rates of patient harm. A May 2016 report from Johns Hopkins Medicine pointed out that deaths from medical errors still outpace those from the third leading cause of death: respiratory disease.

Patient safety mistakes accounted for nearly 250,000 patient deaths at the time of the Johns Hopkins report, outpacing death tolls from respiratory disease by nearly 100,000 incidents.

There’s still a lot of room for improvement, despite the strides the industry has made in the past 20 years.

“We need to continue the existing work, especially around using skills to prevent errors,” Clapper suggested. “We should be using clinical simulation more to build those skills as practice habits and join them into the clinical protocols. Simulations integrate skills as one with the work of being a clinician, instead of something in addition to the work.”

The state of the industry itself, which bombards clinicians with countless requirements for meeting new payment models and fulfilling reporting demands, is keeping organizations from fully focusing on safety.

“Our work doesn't sustain as well as it could or should because of other needs,” Clapper explained.

Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety.

“We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.”

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