Institute of Medicine. 2000. To Err is Human, Building a Safer Health System.

"Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalization respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented.
    "When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1977, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York study suggest the number may be as high as 98,000. Even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th-leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).
    "National costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion, or which health care costs represent over one-half."  (pp. 3-4)

    "Much can be learned from the analysis of errors.  All adverse events resulting in serious injury or death should be evaluated to assess whether improvements in the delivery system can be made to reduce the likelihood of similar events occurring in the future. Errors that do not result in harm also represent an important opportunity to identify system improvements having the potential to prevent adverse events. Preventing errors means designing the health care system at all levels to make it safer. Building safety into processes of care is a more effective way to reduce errors than blaming individuals (some experts, such as Deming, believe improving processes is the only was to improve quality). The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error." (pp. 4-5)

Contents:
1. A comprehensive approach to improving patient safety
2. Errors in health care: a leading cause of death and injury
3. Why do errors happen?
4. Building leadership and knowledge for patient safety
5. Error reporting systems
6. Protecting voluntary reporting systems from legal discovery
7. Setting performance standards and expectations for patient safety
8. Creating safety systems in health care organizations
 

Press release re Survey (2002) by the Harvard School of Public Health and the Henry J. Kaiser Family Foundation.

4 IN 10 OF PUBLIC, MORE THAN ONE-THIRD OF PHYSICIANS SAY THEY HAVE PERSONALLY EXPERIENCED MEDICAL ERRORS

Some 42% of the public and more than one-third of U.S. doctors say they or their family members have experienced medical errors in the course of receiving medical care, with significant percentages reporting serious consequences. . . .

However, implementing the actions recommended by experts on medical errors may not be easy.  Despite widespread personal experience, neither the public nor physicians name medical errors as a top problem facing health care and medicine today.  Physicians and the public also disagree about many proposed solutions.

The Harvard and Kaiser researchers discuss their findings in a New England Journal of Medicine article being published on December 12, 2002.  The nationwide survey examined the views of 831 physicians in April-July 2002 and 1,207 adults in April-June 2002.

“One of the striking findings of this study is that physicians disagree with national experts on the effectiveness of many of the
proposed solutions to the problem of medical errors,” said Robert Blendon, Sc.D., professor of Health Policy at the Harvard School
of Public Health.

“This survey provides strong documentation that medical errors represent a problem that affects a significant number of people,”
said Drew Altman, Ph.D., president and CEO of the Kaiser Family Foundation.  “The fact that so many physicians report personal
experiences with errors corroborates what we heard from the public,” Altman added.

Experience with Medical Errors

Both physicians and the public were read a common definition of a medical error early in the survey.  Subsequently, 35% of physicians and 42% of the public reported experiencing a medical error in their own care or that of a family member at some point in their life; 18% of physicians and 24% of the public said an error caused “serious health consequences” such as death (reported by 7% of
physicians and 10% of the public), long-term disability (6% and 11%, respectively) or severe pain (11% and 16%, respectively).

Three in 10 (29%) of all doctors said that in their role as a physician they had seen a medical error that resulted in serious
harm to a patient in the last year, and a majority of those who had seen an error said it is “very likely” (15%) or “somewhat
likely” (45%) that they would see a similar one at the same institution in the next year.

Not Viewed As A Top Problem Facing Health and Medicine

Doctors and the public agree that as many as half of the deaths due to medical errors could have been prevented, but neither group
listed medical errors among the top “problems facing health care and medicine in the country today.”  Only 5% of physicians and
6% of the public identified medical errors as a top concern.

Instead, when asked to name in an open-ended question the top problems facing health care and medicine today physicians identified
malpractice insurance costs and lawsuits (29%), health care costs (27%), and problems with insurance companies and health plans (22%). The public cited the cost of health care (38%) and cost of prescription drugs (31%) as the top problems facing health care and medicine.

Preventing Medical Errors?

Doctors and the public differ in their views of the most effective ways of reducing medical errors.  Much of the public agreed that
nine of the 16 offered proposals could be very effective, but a majority of practicing physicians saw just two proposals as very
effective: requiring hospitals to develop systems to avoid medical errors (55%) and increasing the number of hospital nurses (51%).

Physicians and the public disagree substantially in their views on some of the key proposals:
* Seven in 10 of the public (71%) said requiring hospitals to report errors to a state agency would be very effective, compared with
23% of physicians.
* A majority of the public (62%) said reports of serious errors should be released publicly; just 14% of physicians agreed, with
most doctors (86%) saying hospital reports should remain confidential.
* Half of the public (50%), but only 3% of physicians, said that suspending the licenses of health professionals who make medical
errors would be a very effective solution for reducing errors.
* Two-thirds of the public said it would be very effective to reduce the work hours of physicians in training (66%) compared to
33% of physicians.

Although few physicians said that more malpractice suits could be effective in preventing individual errors, a majority believes that
surgeons who make errors with serious consequences should be subject to lawsuits.

Gap Between Medical Error Experts and Views of Physicians and the Public

Physicians and the public do not necessarily agree with the views of experts regarding the effectiveness of certain approaches to reducing errors. For example, less than a majority of both physicians and the public believes that limiting certain high-risk procedures to high volume centers (40% of physicians, 45% of public), increasing use of computerized medical records (19% and 46%, respectively), or use of computers in ordering of medical tests and drugs (23% and 45%, respectively) would be very effective solutions.

Furthermore, about one-third of physicians (34%) agree that another key proposal of experts - using only physicians trained in intensive care medicine in hospital ICUs - would be very effective.

Causes of Medical Error

Physicians said the leading causes of errors are a shortage of nurses (53%) and overwork, stress or fatigue of health professionals (50%).  A majority of the public identified seven causes; the top four they cited are physicians not having enough time with patients (72%); overwork, stress or fatigue of health professionals (70%), health professionals not working together or communicating as a team (67%) and a shortage of nurses (65%).

About seven in 10 physicians thought an error would be more likely at a hospital that does fewer procedures.  The public was less sure, with about half saying that an error would be more likely at a low-volume center and the other half saying that errors would be more likely at a high-volume center (23%) or that volume would make no difference (26%).
 

Institute of Medicine. 2001. Crossing the Quality Chasm. 

"This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee's first report, To Err Is Human: Building a Safer Health System, was released in 1999 and focused on a specific quality concern--patient safety. this second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care." (p.ix)

Contents:
1. A new health system for the 21st century
2. Improving the 21st-century health care system
3. Formulating new rules to redesign and improve care
4. Taking the first steps
5. Building organizational supports for change
6. Applying evidence to health care delivery
7. Using information technology
8. Aligning payment policies with quality improvement
9. Preparing the workforce
 
Institute of Medicine. 2005. Performance Measurement: Accelerating Improvement.

This is the first report from the Redesigning Health Insurance Performance Measures, Payment, and Performance Project. The Institute of Medicine initiated this project in 2004, in response to mandates in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Two other reports are expected in 2006, concerned with payment incentives and quality improvement initiatives. The three reports will constitute the IOM's Pathways to Quality Health series.