As patients and providers struggle with the increased complexity of modern medicine (Chapter 2), the nation struggles with the clear and compelling imperative to improve the value of health care—that is, to achieve better outcomes at lower cost. The challenges of complexity and value are closely linked as the central dilemmas driving the need for attention to opportunities for the continuous learning and improvement that is the focus of this report.


Currently, the U.S. health care system is failing to achieve its potential in either the quality of care or the outcomes of care. These shortfalls can be seen in areas as diverse as patient safety, the evidence basis for care, care coordination, access to care, and health disparities. If the health care system is to realize its potential, a concerted effort to learn and improve on each of these dimensions will be necessary.

Patient Safety

More than a decade ago, the Institute of Medicine (IOM) released To Err Is Human: Building a Safer Health System, in which it was estimated that at least 44,000 people, and perhaps as many as 98,000, died in hospitals every year as a result of preventable medical errors (1999). Ten years later, as illustrated in Box 3-1, medical errors still occur routinely (Downey et al., 2012). A study of 10 North Carolina hospitals over a 5-year period, for example, found that approximately 18 percent of patients were harmed by medical care, with 63 percent of those cases being judged as preventable (Landrigan et al., 2010). This finding was reinforced by a nationwide study revealing that one in seven Medicare patients suffered harm from hospital care, with an additional one in seven suffering temporary harm from care-related problems that were detected in time and corrected; 44 percent of these errors were found to be preventable (Levinson, 2010). A third study found that the rate of adverse events in hospitals could be as high as one-third of all admissions (Classen et al., 2011). One of the difficulties of measuring the magnitude of medical errors is that they often are unreported. A recent study found that 86 percent of adverse events were not submitted to existing hospital incident reporting systems, partly because of confusion about what constitutes patient harm (Levinson, 2012). These errors carry substantial financial costs, lengthen patients’ hospital stays, and in some cases increase mortality (Zhan and Miller, 2003).

Although infections and complications once were viewed as routine consequences of medical care, it is now recognized that strategies and evidence-based interventions exist that can significantly reduce the incidence

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