Medical Mistakes, 10 Years Post-Op

It’s November 1999, and the release of an advance copy of a breakthrough Institute of Medicine (IOM) report on patient safety provokes headlines around the world with its estimate that as many as 98,000 people per year die from medical errors in U.S. hospitals. The report and subsequent book, To Err is Human: Building a Safer Health System, already is labeled a landmark event for modern medicine.1 It launches a nationwide effort to systematically improve patient safety and reduce errors.

Believe it or not, the IOM report celebrates its 10th anniversary this month. Many healthcare leaders point out that the QI and patient-safety revolution birthed by the IOM report has paralleled the simultaneous—and seismic—growth of HM.

The IOM report drew upon data from Harvard Medical Practice Studies and other existing research for its shocking estimates of error-induced deaths. The report, to a large degree, focused on prescribing errors, with less emphasis on hospital-acquired infections and other safety and quality issues that have emerged since its publication. The report also proposed a comprehensive safety strategy for government, industry, consumers, and healthcare providers—a proposal that has been adopted only in pieces.

In commemorating the 10th anniversary of the IOM report, industry leaders agree that HM more than any other medical specialty will continue to play a leading role in pushing the quality and patient-safety agenda in hospitals throughout America.

IOM’s Committee on Quality of Healthcare in America, which was made up of physicians, researchers, and healthcare leaders, authored the breakthrough report on medical errors, and followed up two years later with Crossing the Quality Chasm: A New Health System for the 21st Century (

The Hospitalist caught up with two of the original committee members, Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI), and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM), to discuss how far medicine has come—and how far it has to go—in the areas of hospital quality and patient safety.

Christine Cassel, MD, president, CEO, American Board of Internal Medicine, PhiladelphiaWhen we think about how we train doctors … they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change.

—Christine Cassel, MD, president, CEO, American Board of Internal Medicine, Philadelphia

Question: What is the legacy of the IOM report?

Dr. Berwick: It didn’t launch the patient-safety movement, but it was the most important single contributor to that movement. In one step, it took the focus on safety as a goal in medicine from a relatively fringe concern to a central issue, and a central task for health providers.

Its most important element was the focus on systems improvement, rather than exhortations to individual health professionals to do a better job with patient safety. It is a cultural norm to blame someone when something goes wrong. That hasn’t changed fundamentally. But the IOM report made the point that it’s not people who are to blame for problems in patient safety, and blame won’t get us where we need to go.

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