To Err is Human – To Delay is Deadly

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Ten years later, a million lives lost, billions of dollars wasted
Executive Summary

Ten years ago the Institute of Medicine (IOM) declared that as many as 98,000 people die each year needlessly because of preventable medical harm, including health care-acquired infections.Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.

Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year. This needless death is unacceptable, and we must demand action from our health-care system.

In this report we give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.

Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes. While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.

A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.

No national entity has been empowered to coordinate and track patient safety improvements. Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.

Doctors and other health professionals are not expected to demonstrate competency. There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The U.S. health-care system needs nationwide mandatory, validated and public (MVP) reporting of preventable health care-acquired infections and medical errors. Medication errors—cited as a major problem by the IOM ten years ago—remain a serious problem today. The FDA, doctors, hospitals, and drug manufacturers must establish better practices at every stage of the treatment process to track and prevent harm from medication errors. Professional standards regarding patient safety should ensure competent care. While some progress has been made by private initiatives and through purchasing policies, regulators have not demanded universal competency testing for doctors and nurses.

Doctors and hospitals raise concerns that public reporting of medical harm will lead to frivolous lawsuits. But the best way to prevent claims is to put systems in place to prevent harm. Experience with public reporting in the states demonstrates the tort concerns about such disclosures is overstated. With a civil justice system weakened by limited compensation to harmed patients and inadequate oversight of health care, public reporting of preventable medical harm is today perhaps the only effective accountability measure we have.

The current health reform debate presents a remarkable opportunity for improving access to health care in America but that health care should be safe. Patient safety needs to be a major part of these reforms.