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 (www.iom.edu/?id=12736).2
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.
When 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.
HM Jumps into Quality and Patient Safety with Both Feet
An incredible, happy coincidence: That is how Robert Wachter, MD, FHM, explains the paralleled growth of HM and patient-safety awareness in U.S. hospitals. HM had “just emerged in the mid-1990s and was still figuring out what it was about when the IOM report [To Err is Human] was published,” says Dr. Wachter, chief of the hospital medicine division, professor and associate chair of the Department of Medicine, the University of California at San Francisco, former SHM president and author of the blog “Wachter’s World,” noting concerns at the time that HM would be branded as a cost-saving measure for hospitals and health plans.
“I remember vividly when the IOM report came out. A light bulb went off for me—what a spectacular opportunity for our field,” the well-known HM pioneer recalls. “Here was this huge report saying patient safety stinks and needs to be fixed. I was pretty sure other medical specialties would not welcome the findings. I and other hospitalist leaders pushed very hard to say ‘we own this’—we believe the report is true and we believe it requires a new kind of physician who believes in systems thinking, teamwork, and collaboration. I still think it was a good call for hospital medicine to jump with both feet into the quality and safety field.”
The IOM report sparked a patient-safety renaissance, Dr. Wachter says. “We recognized that there is a science here—a core knowledge, a way of thinking and an understanding that we were not going to make much progress on patient safety until we understood that knowledge, learned its science, and did the research. We have since learned that fixing patient safety is tricky, and yet as you scan the landscape, you see all of the important actors are doing something to make patient care safer.”
One of the first steps to fixing the problem is “owning up” to the fact people die because of medical mistakes. Hospitals’ willingness to adopt transparency, from the first floor to the C-suite, has changed in the past decade, Dr. Wachter says.
“We have created an environment where we’re on the path to getting safer,” he says. “We’re much more open and honest about errors. We attack them with root-cause analysis and find better ways to fix the problem. For me, that’s all healthy. It leaves me with great confidence that things are safer in American hospitals than they were 10 years ago—although certainly not as safe as they need to be.”—LB
