Administration had already gotten a start on the topic, thanks to Ken Kaiser’s leadership, with the help of colleagues there. That was December 1999.

We’ve come a really long way. Even while we have enormous challenges now that we’ll speak about at this meeting, it’s worth just celebrating a little. Awareness is very high now. We have tons of empirical evidence that the problem is abundant. We had the most recent studies this year, Dave Classen’s report in Health Affairs that the Secretary mentioned, the Office of the Inspector General with the report on Medicare beneficiaries showing a 13.5 percent injury rate. And Chris Landrigan’s study in North Carolina, which confusingly shows not much progress against all-cause injury in that state. We have data, though, and that’s a great place to start.

We also have the best minds now. The best engineers and safety scientists in the world are now engaged in health care. Some of them are hooked on health care: Jim Reason, Carl Weick, David Woods, a long list, got to add Paul O’Neill, a pioneer who didn’t begin in health care, but now is helping lead our whole country into thinking differently about reliability in health care systems.

And we have the major systems that the Secretary is referring to and others that have just cast a light. They have shown what’s possible—Ascension Health, she mentioned Virginia Mason, Mayo Clinic has done tremendous work, Centura, and Henry Ford Health System. I see Bill Corley in the audience, who almost single-handedly is beginning to turn Indiana into an example for us all.

And in some sense, we have results beyond anything I could possibly have thought even remotely achievable back in those 1999 days. I thought that we could drive central line infections to zero in hospitals for years, year upon year, or that ventilated pneumonias could essentially be abolished, or pressure ulcers cut 95 percent as dissension is done.

Seton Northwest in Austin, where the Secretary will visit, has now, last year, 10,000 consecutive deliveries with only one birth injury. These are rates of achievement that I would not have thought possible. And we have one great example of excellence to scale now in this country with the progress against central line infection now, thanks to Carolyn’s leadership and others. We know we can do it as a nation, not just as an institution.

That is to celebrate, but it also sets us up for what we have yet to do, which is more important, and that is, as the Secretary said, to go to scale, full scale. I don’t see any reason why any American in any hospital



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement