Five years after To Err Is Human: what have we learned?

Area of Science:

• Healthcare Quality and Safety
• Health Systems Research
• Patient Care Improvement

Background:

• The Institute of Medicine (IOM) previously called for national patient safety improvements.
• Progress has been gradual, but the IOM report significantly shifted focus to systemic changes.
• Stakeholder engagement and hospital adoption of safe practices have increased.

Purpose of the Study:

• To assess the impact of the IOM's call for national patient safety efforts.
• To identify key areas for accelerating patient safety improvements.
• To advocate for a national commitment to ambitious patient safety goals.

Main Methods:

• Review of progress and impact following the IOM's 2005 report.
• Analysis of trends in patient safety initiatives.
• Identification of potential future drivers of safety improvement.

Main Results:

• The IOM report successfully reframed the patient safety conversation towards systems.
• Key areas for acceleration include electronic health records, safe practice diffusion, team training, and disclosure.
• Pay-for-performance models could incentivize safety if targeted effectively.

Conclusions:

• Significant progress in patient safety requires a sustained national commitment.
• Setting strict, ambitious, and measurable national goals is crucial for substantial improvement.
• The Agency for Healthcare Research and Quality should convene stakeholders to establish these goals by 2010.