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

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA
• Reviewers
• Preface
• Foreword
• Acknowledgments
• Executive Summary
  • Recommendations
  • Summary
  • References
• 1. A Comprehensive Approach to Improving Patient Safety
  • Patient Safety: A Critical Component of Quality
  • Organization of the Report
  • References
• 2. Errors in Health Care: A Leading Cause of Death and Injury
  • Introduction
  • How Frequently do Errors Occur?
  • Factors that Contribute to Errors
  • The Cost of Errors
  • Public Perceptions of Safety
  • References
• 3. Why Do Errors Happen?
  • Why Do Accidents Happen?
  • Are Some Types of Systems More Prone to Accidents?
  • Research on Human Factors
  • Summary
  • References
• 4. Building Leadership and Knowledge for Patient Safety
  • Recommendations
  • Why a Center for Patient Safety is Needed
  • How Other Industries Have Become Safer
  • Options for Establishing a Center for Patient Safety
  • Functions of the Center for Patient Safety
  • Resources Required for a Center for Patient Safety
  • References
• 5. Error Reporting Systems
  • Recommendations
  • Review of Existing Reporting Systems in Health Care
  • Discussion of Committee Recommendations
  • References
• 6. Protecting Voluntary Reporting Systems from Legal Discovery
  • Recommendation
  • Introduction
  • The Basic Law of Evidence and Discoverability of Error-Related Information
  • Legal Protections against Discovery of Information about Errors
  • Statutory Protections Specific to Particular Reporting Systems
  • Practical Protections against the Discovery of Data on Errors
  • Summary
  • References
  • Bibliography
• 7. Setting Performance Standards and Expectations for Patient Safety
  • Recommendations
  • Current Approaches for Setting Standards in Health Care
  • Performance Standards and Expectations for Health Care Organizations
  • Standards for Health Professionals
  • Standards for Drugs and Devices
  • Summary
  • References
• 8. Creating Safety Systems in Health Care Organizations
  • Recommendations
  • Introduction
  • Key Safety Design Concepts
  • Principles for the Design of Safety Systems in Health Care Organizations
  • Medication Safety
  • Summary
  • References
• Appendixes
  • A Background and Methodology
  • B Glossary and Acronyms
  • C Literature Summary
  • D Characteristics of State Adverse Event Reporting Systems
  • E Safety Activities in Health Care Organizations

Support for this project was provided by The National Research Council and The Commonwealth Fund. The views presented in this report are those of the Institute of Medicine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.