What Have We Learned?

FIVE YEARS AFTER THE INSTITUTE of Medicine (IOM) reported that as many as 98 000 people die annually as the result of medical errors and called for a national effort to make health care safe, it is time to assess our progress. Is health care safer now? And, if not, why not? The IOM’s report, To Err Is Human: Building a Safer Health System, galvanized a dramatically expanded level of conversation and concern about patient injuries in health care both in the United States and abroad. Patient safety, a topic that had been little understood and even less discussed in care systems, became a frequent focus for journalists, health care leaders, and concerned citizens. Small but consequential changes have gradually spread through hospitals, due largely to concerted activities by hospital associations, professional societies, and accrediting bodies. All hospitals have implemented some new practices to improve safety. Fewer patients die from accidental injection of concentrated potassium chloride, now that it has been removed from nursing unit shelves; fewer patients have complications from warfarin, now that many taking anticoagulants are being treated in dedicated clinics; and serious infections have been reduced in hospitals that have tightened infection control procedures ( J. Whittington, written communication, March 2005; K. McKinley, Geisinger Clinic, written communication, April 2005; and P. Pronovost, Johns Hopkins Hospital, written communication, January 2005). Although these efforts are affecting safety at the margin, their overall impact is hard to see in national statistics. No comprehensive nationwide monitoring system exists for patient safety, and a recent effort by the Agency for Healthcare Research and Quality (AHRQ) to get a national estimate by using existing measures showed little improvement. Although that estimate was largely based on insurance claims data, measures known to have low sensitivity for detecting quality improvement, little evidence exists from any source that systematic improvements in safety are widely available. Perhaps inevitably, critics have pushed back against viewing safety as a problem of science—of system design. Public support for improving patient safety often turns instead on fixing blame. Despite the widely disseminated message from the IOM that systems failures cause most injuries, most individuals still believe that the major cause of bad care is bad phyicians, and that if miscreant clinicians were removed everything would be all right. Some have claimed that the emphasis on systems, and particularly, not blaming individuals for errors, will weaken accountability for physician performance. Related concerns have led to legislation imposing stricter reporting requirements on hospitals and physicians. The latest surge in the malpractice premium crisis has deflected interest of lawmakers from error prevention to an effort to put caps on malpractice settlements. Although the proven measured fruits of the IOM report so far are few,