Revisiting To Err Is Human 20 years later

The Institute of Medicine (IOM, now known as the National Academy of Medicine) 20 years ago published the landmark report, To Err Is Human: Building a Safer Health System. This report increased awareness of medical errors in the U.S. and also called for health care system changes that would lead to improvements in patient safety and quality of care.

The report cited a study that estimated at least 44,000 patients die annually in the U.S. as a result of medical errors, with an additional study suggesting it could be as high as 98,000.¹ The report also stated that deaths attributed to medical errors exceeded “the number attributable to the eighth-leading cause of death,” which at the time was suicide.^1-3 More importantly, the report highlighted the fact that most medical errors were the result of failures of the system rather than specifically attributable to individuals.¹

Still work to be done

Two decades later, Mark R. Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission—a member of the IOM Committee on Quality of Health Care in America that wrote the To Err Is Human report—believes that although that report and others have led to improvements in the health care system, the rates of familiar quality issues remain too high.

For surgeons, quality issues that still demand attention include wrong-site surgery and the continued incidence of unintended retained foreign objects (URFOs). URFOs were the top sentinel event reported to The Joint Commission in 2017 (124 reported) and again in 2018 (121 reported). A total of 104 incidents of wrong-patient, wrong-site, wrong-procedure events were reported in 2017, with another 98 reported in 2018.

Dr. Chassin touched on the To Err Is Human report and more in a Modern Healthcare editorial, “One-size-fits-all approach to patient safety improvement won’t get us to the ultimate goal—zero harm.” Dr. Chassin laid out three changes health care leadership can make to ensure patients receive higher quality care. They are as follows:³

• Commit to a goal of zero harm
• Drastically overhaul the institutional culture
• Understand that safety processes often fail at rates of 50 percent or more

In the Modern Healthcare commentary, Dr. Chassin also wrote that “the method we have employed is the ‘one-size-fits-all’ best practice.”³ But that approach often leads to modest or inconsistent improvements that are difficult to sustain over time.

“We cannot continue to use the same methods and expect different results,” Dr. Chassin wrote. “Evidence is accumulating that process improvement methods long used successfully in industry—Lean, Six Sigma and change management, taken together—are far more effective than the ‘one-size-fits-all’ best-practice approach.”³

Dr. Chassin also spoke with Nancy Foster, American Hospital Association vice-president for quality and patient safety, for the Advancing Health podcast. In the episode, Dr. Chassin described the impact of the To Err Is Human report on health care safety.⁴

Now what?

So where do we go from here? In a recent High Reliability Healthcare blog post, Dr. Chassin reflected on the future impact of To Err Is Human and how health care can continue to improve. “We’ve made some significant progress, but the next major gains will arise only from the efforts of health care leadership and organizations, not government, business, market forces, nor patient advocacy groups,” Dr. Chassin wrote.⁵

He also asked that after 20 years, “Who is satisfied with the current state?” He noted, “If we’re not satisfied, we need to change the way we have been going about improvement.”⁵

My personal take on the IOM report is positive. I believe that before the report was published, health care leaders were primarily focused on innovation. The report marked a pivotal moment in the health care industry, policymaking, and society’s expectations about how health care is provided. Starting in early 2000 (the report was released in November 1999), attention rapidly shifted from a focus on innovation as a way to advance health care to a focus on safety. That movement toward safety has grown ever since, and that, I believe, has provided enormous benefits to our patients.⁶

Am I satisfied with the rate of harm surgical patients continue to experience? Of course not. However, safety is not a static goal line but rather a moving target. New processes, new devices, new ways of providing treatment—yes, innovation—continues full throttle, and while these advances have benefited society in a significant way, they also have created vulnerability and risks that were not present before. Managing those risks, creating a culture of safety, and continuing to focus on ways to identify and eliminate threats before they become errors is, in my view, the greatest legacy of this report and a moral imperative for every surgeon.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

References

1. Institute of Medicine (U.S.) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. Executive Summary. Available at: www.ncbi.nlm.nih.gov/books/NBK225179/. Accessed December 30, 2019.
2. National Vital Statistics Reports. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final data for 1997. June 30, 1999. Available at: www.cdc.gov/nchs/data/nvsr/nvsr47/nvs47_19.pdf. Accessed December 30, 2019.
3. National Vital Statistics Reports. Centers for Disease Control and Prevention (National Center for Health Statistics). Births and deaths: Preliminary data for 1998. October 5, 1999. Available at: www.cdc.gov/nchs/data/nvsr/nvsr47/nvs47_25.pdf. Accessed December 30, 2019.
4. Chassin M. One-size-fits-all approach to patient safety improvement won’t get us to the ultimate goal—zero harm. Mod Healthcare. Available at: www.modernhealthcare.com/opinion-editorial/one-size-fits-all-approach-patient-safety-improvement-wont-get-us-ultimate-goal. Accessed December 30, 2019.
5. American Hospital Association patient safety leader reflects on ‘To Err is Human’ report. Advancing Health. Available at: www.aha.org/advancing-health-podcast/2019-11-13-patient-safety-leader-reflects-err-human-report. Accessed December 30, 2019.
6. Chassin M. To Err is Human: The next 20 years. The Joint Commission High Reliability Healthcare blog. Available at: www.jointcommission.org/resources/news-and-multimedia/blogs/high-reliability-healthcare/2019/11/to-err-is-human-the-next-20-years/. Accessed December 30, 2019.