National Academies Press: OpenBook

To Err Is Human: Building a Safer Health System (2000)

Chapter: A Background and Methodology

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Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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A—
Background and Methodology

This report on patient safety is part of a larger study examining the quality of health care in America. The Quality of Health Care in America project was initiated by the Institute of Medicine in June 1998, with the charge of developing a strategy that will result in a threshold improvement in quality over the next ten years. Specifically, the committee is charged with the following tasks:

• review and synthesis of findings in the literature pertaining to the quality of care provided in the health care system;

• development of a communications strategy for raising the awareness of the general public and key stakeholders of quality-of-care concerns and opportunities for improvement;

• articulation of a policy framework that will provide positive incentives to improve quality and foster accountability;

• identification of key characteristics and factors that enable or encourage providers, health care organizations, health plans, and communities to continuously improve the quality of care; and

• development of a research agenda in areas of continued uncertainty.

A growing body of rigorous research has documented serious and widespread quality problems in American medicine. The burden of harm con-

Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 206

veyed by the collective impact of all of our health care quality problems requires the urgent attention of all stakeholders—the health professions, health policy makers, consumer advocates, and purchasers of care. The challenge is to bring the full potential benefit of effective health care to all Americans while avoiding unnecessary and harmful interventions and eliminating preventable complications of care. Meeting this challenge demands a readiness to think in radically new ways about how to deliver health care services and how to assess and improve their quality. Yet neither business leaders, medical leaders, policy makers, nor the public has a clear picture about whether different forms of financing and delivery of care have affected the quality of care and how best to structure financing, oversight, and delivery of care to improve quality.

The methods used for this study included a review of available literature, a commissioned paper, public testimony, a telephone survey, and input from targeted groups on specific issues. A review of the literature relied on published articles focusing on areas of quality, medical errors, patient safety, aviation safety, worker safety, and pharmaceutical safety. Working papers and web sites were also consulted, generally provided by organizations involved in patient safety, accreditation, and existing error reporting systems.

A paper was commissioned on the legal issues raised in protecting data and reporters in error reporting systems that are external to a health care organization. This paper was completed for the committee by Randall Bovbjerg, J.D., and David Shapiro, M.D., J.D. It formed the basis for Chapter 6 of this report.

The content of this report was discussed at seven meetings of two different subcommittees. It was on the agenda at four meetings of the Subcommittee on Creating an External Environment for Quality and three meetings of the Subcommittee on Creating the 21st Century Health System. It was also on the agenda at three meetings of the Committee on Quality of Health Care in America. The public testimony provided follows:

Subcommittee on Creating an External Environment for Quality

November 2, 1998

Martin Hatlie, National Patient Safety Foundation
Michael Cohen, Institute for Safe Medication Practices
Ronald Goldman, Veterans Health Administration

Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 207

January 29, 1999

Charles Billings, M.D., Ohio State University (designer of the Aviation Safety Reporting System)

June 15, 1999

Tim Cuerdon, Health Care Financing Administration
Margaret VanAmringe, Joint Commission on Accreditation of Health Care Organizations
Marge Keyes, Agency for Healthcare Research and Quality

Joint Meeting of Both Subcommittees

June 16, 1999

Kenneth Kizer, M.D., Undersecretary of Health, Veterans Health Administration

A short telephone survey was conducted between February 24 and May 5, 1999 of a number of states having error reporting systems that affect hospitals. The list of states was obtained from the Joint Commission on Accreditation of Healthcare Organizations. A nonrepresentative sample was chosen to obtain additional information on their programs, focusing mainly on the largest states. The respondent was the individual at the state health department with administrative responsibility over the reporting program. Information was collected on the definition of a reportable event, which organizations submit reports, the number of reports submitted in the most recent year available, the year the reporting program was implemented, who has access to the information reported, and what is done with the information obtained (e.g., organization follow-up on specific events, compilation of data and trending over time). All respondents were given an opportunity to review the information on their states and make any corrections or clarifications.

Finally, input was obtained through two group meetings with specific key audiences. The first meeting was a 90-minute discussion held on August 2, 1999, at the 12th Annual Conference of the National Academy for State Health Policy in Cincinnati, Ohio. This meeting was attended by 19 people, all of whom had responsibilities associated with quality-of-care issues, some related to state error reporting programs. Open discussion was held on roles that states can play in ensuring adequate oversight of quality-of-care and patient safety, and what would be helpful to the states to increase their efforts in safety oversight.

The second meeting was a one-day roundtable discussion held on Sep-

Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 208

tember 9, 1999, with health professionals active in their professional societies and associations through support from The Commonwealth Fund. This meeting was attended by 14 people representing medicine, nursing, and pharmacy. This open discussion covered issues related to the extent to which the health and medical community is aware of quality and safety concerns, specific actions that professional societies and groups can take to improve patient safety, and barriers that impede these actions from moving forward.

Other IOM Work on Quality

This quality initiative represents a continuing IOM interest in quality of health care. Several other quality-of-care projects have been undertaken in recent years.

America's Health in Transition: Protecting and Improving the Quality of Health and Health Care (IOM-wide special initiative)

The Special Initiative on Health Care Quality was created in 1996 to examine how to maintain and improve the health and well-being of the population and the quality of care that the public receives as the health care system restructures. This special initiative is evaluating quality assessment and improvement tools and their uses, and promoting the application of appropriate tools at all levels of health care, in all organizations, for the entire population. The initiative will also inform consumers, policy makers, providers, and others of key opportunities and obstacles to achieving better health outcomes for individuals and populations, and will provide them with information and tools to enable them to make better decisions and choices about health and health care.

National Roundtable on Health Care Quality

The National Roundtable on Health Care Quality was created to examine continual changes in health care and the implications of these changes for the quality of health and health care in this nation. The Roundtable convened nationally prominent representatives of the private and public sectors (regional, state, and federal); academia; patients; and the health media to analyze unfolding issues concerning health care quality. This initiative produced three reports: The Urgent Need to Improve Health Care Quality, Mea-

Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 209

suring the Quality of Health Care, and Collaboration Among Competing Managed Care Organizations for Quality Improvement.

Ensuring the Quality of Cancer Care

The National Cancer Policy Board undertook a comprehensive review of the quality of cancer care provided in the United States. The report, published in June 1999, delineates essential elements needed to improve quality in cancer care. The report provides an overview of the present cancer care system, moving from detection and early treatment to care at the end of life. Major obstacles impeding patient access to quality cancer care are identified. The report offers a model of an ideal cancer care delivery system and provides examples of the problems that limit early detection, accurate diagnosis, optimal treatment, and responsive supportive care. Recommendations to improve the quality of cancer care are offered for consideration by Congress, public and private health care purchasers, individual consumers, providers and researchers.

Improving Quality in Long-Term Care

The Committee on Improving Quality in Long-Term Care was convened to examine the means for assessing, overseeing, and improving the quality of long-term care in different settings and the practical and policy challenges of achieving a consistent quality of care regardless of where care is received. This study built on a 1986 report, Improving the Quality of Care in Nursing Homes, which initiated changes that significantly altered where long-term care is received and by whom. The most recent study examines the full range of long-term care settings and services, including nursing homes, assisted living facilities, and community-based home health care.

Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 205
Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 206
Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 207
Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 208
Suggested Citation:"A Background and Methodology." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 209
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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