20 years later: Reflections on the snowball effect of “To Err is Human”

Posted on: 11/8/19

The Institute of Medicine (IOM) released the landmark publication “To Err Is Human” on Nov. 29, 1999, stating upwards of 98,000 patients died in hospitals each year from preventable errors. The report emphasized that human error is a component of every complex system involving human beings, and preventing injury and death from medical error requires a focus on systemwide change. Additionally, preventing injury and death from error includes the design of processes that recognize human strengths and weaknesses that prevent, recognize and mitigate harm from error. Thus, the patient safety movement was born.

Here are some memorable (and landmark) patient safety works and leaders that have emerged during the 20 years following publication of "To Err is Human":

• 2000: The Agency for Healthcare Research and Quality (AHRQ) released “Doing What Counts for Patient Safety”;
• 2001: Peter Pronovost, MD, a professor at Johns Hopkins University School of Medicine, developed a five-step checklist to eliminate central line infections. He asked Hopkins staff to use it whenever they inserted a line. That effort yielded a drop in the infection rate from 11% to zero. The success was then spread to more than 100 Michigan hospitals as part of the Keystone ICU Project, also incorporating steps to create a strong safety culture. The project impact was huge: a 66% reduction in rates of central line associated blood stream infections in an 18-month period.
• 2002: The Surviving Sepsis Campaign (SSC), joint international collaboration of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) committed to reducing mortality and morbidity from sepsis and septic shock worldwide. The SSC eventually created evidence-based guidelines for the early identification and treatment of sepsis.
• 2003: AHRQ released a set of Patient Safety Indicators, measures to screen for adverse events.
• 2003: The Joint Commission released the first set of standards as part of The National Patient Safety Goals program.
• 2004: The Institute for Healthcare Improvement (IHI) launched the 100,000 Lives Campaign. The goal: to reduce preventable deaths over 18 months by taking six key steps to reduce patient harm. The IHI reported 122,000 fewer preventable deaths over the course of the initiative.
• 2005: Congress develops the federal Patient Safety and Quality Improvement Act providing a structure for Patient Safety Organizations (PSOs).
• 2006: The IHI initiated a two-year 5 Million Lives Campaign, enrolling and engaging more than 4,000 hospitals to utilize evidence-based guidelines to prevent hospital-acquired harm.
• 2007: The World Health Organization (WHO) launched the global challenge Safe Surgery Saves Lives, convening experts and patients from around the world to identify key surgical concerns, focusing on surgical site infection, safe anesthesia, safe surgical teams, and measurement of surgical services.
• 2008: WHO published guidelines with recommended safe surgical practices and Atul Gawande and his team from Harvard created a surgical safety checklist.
• 2011: AHRQ released the National Scorecard on Hospital-Acquired Conditions.
• 2011: The Centers for Medicare & Medicaid Services’ (CMS) Innovation Center initiated The Partnership for Patients in April 2011 as a public-private partnership offering support to physicians, nurses and other clinicians to make patient care safer.
• 2012: Twenty-six Hospital Engagement Networks were formed as part of the Partnership for Patients campaign to reduce harm and improve the quality and safety of health care. Sixty Oklahoma hospitals committed to participate with OHA (in partnership) and AHA/HRET to decrease hospital-acquired harm.
• 2013: Patient & Family Engagement emerges as a critical link between hospitals, patients and families to improve quality. AHRQ releases the “Guide to Patient and Family Engagement in Hospital Quality and Safety,” an evidence-based resource to help hospitals work as partners with patients and families.
• 2016: CMS awarded contracts to 16 Hospital Improvement Innovation Networks as part of the integration of the Partnership for Patients (PfP) Hospital Engagement Networks (HEN) into the Quality Improvement Network-Quality Improvement Organization (QIN-QIO) program. More than 4,000 hospitals across 16 Hospital Improvement Innovation Networks (HIINs) are participating in Partnership for Patients. Forty-three Oklahoma hospitals participate in OHA HIIN (in partnership with AHA/HRET) to decrease hospital-acquired harm.
• 2019: CDC published the "2018 National and State Healthcare-Associated Infection (HAI) Progress Report". This report shows that the U.S. has made significant reductions in several types of HAIs and highlights areas where more improvements are needed. The national progress in reducing HAIs (CLABSI-9% decrease, CAUTI-8% decrease, C. difficile infections-12% decrease) shows that prevention is possible.

The OHA Clinical Initiative staff continue work with hospitals to reduce hospital-acquired harm and readmissions. Hospital successes will be highlighted during the next several months in Hotline.

Jonathan Perlin, MD, president of clinical services and chief medical officer at HCA Healthcare and former chairman of the AHA Board of Trustees; and Nancy Foster, AHA vice president for quality and patient safety, discuss the landmark Institute of Medicine report and progress to build a safer health care system in this podcast.

For additional resources on the 20 years since "To Err is Human", read the articles below:

20 Years of Patient Safety
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety

(Patrice Greenawalt)