More people die from medical errors than from motor vehicle accidents,
breast cancer, or AIDS. 1
10 years ago...
The groundbreaking Institute of Medicine report "To Err is Human" shook the nation by revealing...
44,000 to 98,000 people die each year 2
as a result of preventable medical errors.
Based on voluntary reporting of adverse events.
Today...
Despite 13 years of research and practice in an effort to improve patient safety in our nation's hospitals...
The number of patients harmed in hospitals may be
10 times greater than was
previously estimated 3
New methodologies such as the Global Trigger Tool* are much more precise in detecting errors.
More than one in five Americans say they or a family member have experienced a medical or a prescription drug error in a doctor's office or hospital. 4
What contributes to patient harm?
Medical errors are not the only sources of patient harm. Patients experience harm in hospitals for many reasons, including, but not limited to:
- Insufficient teamwork among clinicians
- Ineffective communication among clinicians and between clinicians, patients, and families
- Poor hospital safety cultures (cultural norms and behaviors that do not demonstrate a commitment to patient safety at every level of the organization)
Why don't hospitals behave like other high-risk industries?
In one month, 13.5% of hospitalized Medicare beneficiaries--that is, 1 in 7, or 134,000 patients--experienced at least 1 adverse event during their hospital stay. 5
The application of teamwork principles and communication protocols are required for organizations in high-risk industries:
Reducing organizational hierarchy and promoting multidisciplinary team training, using tools to achieve continuous quality improvement, and establishing human resource policies and practices 6
Changing organizational dynamics, applying the principles of teamwork, and implementing more effective communication protocols. One way to achieve this is for healthcare to adopt the practices used in other high-risk industries, such as aviation and nuclear power, to create "high reliability organizations," or HROs. Adopting the practices of HROs will help hospitals to achieve consistent records of excellence in highly complex environments. 7
Requiring hospitals, doctors, and healthcare facilities to submit and make public real-time reporting of adverse medical events and information such as disease-specific mortality, infection rates, and patient satisfaction. 8
Why do we fail to control what is within our reach?
In his book, The Checklist Manifesto, Atul Gawande suggests two reasons:
1. Ignorance
We may err because science has given us only partial understanding of the world and how it works.
2. Ineptitude
The knowledge exists, yet we fail to apply it correctly. 9
* Global Trigger Tool and IHI Global Trigger Tool are trademarks of the Institute for Healthcare Improvement (IHI), Cambridge, Massachusetts, USA (www.ihi.org).
