Improving Patient Safety - Five years after the IOM Report

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P E R S P E C T I V E

Improving Patient Safety — Five Years after the IOM Report

A 1999 report from the Institute of Medicine (IOM)featured a now-familiar statistic: 44,000 to 98,000people die in hospitals each year because of prevent-able medical errors, making hospital-based errorsalone the eighth leading cause of death in the Unit-ed States, ahead of breast cancer, AIDS, and motorvehicle accidents. Regardless of debate about theseestimates, they remain the standard for describingthe scope of the nation’s problem with medicalerrors.

When the report, titled

To Err Is Human: Buildinga Safer Health System,

was released, these numberscaught the public’s attention as few other healthpolicy issues have done. A 1999 survey showed thatthe report was the most closely followed health pol-icy story of the year.

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The subject also grabbed theattention of public and private organizations thatwere in a position to address the quality of U.S.health care. On December 7, 1999, President BillClinton signed an executive order requiring federalagencies and departments to develop, within 90days, a list of activities to make patient care safer.As a result, new programs were initiated at numer-ous agencies.

In the private sector, health care purchasers, in-dustry trade organizations, accrediting and stan-dards-setting bodies, and others embarked on pro-grams of their own. One of the more ambitious wasthat of the Leapfrog Group, a coalition represent-ing large health care purchasers that has advocated“safety leaps” through the use of computerized or-der entry, evidence-based hospital referrals, andphysician staffing in the intensive care unit. Thereis some evidence that these recommendations arebeing adopted: in surveys, 24 percent of respondinghospitals said they had intensive care units staffedby intensivists in 2003, as compared with 12 percentin 2001, and the use of computerized physician or-der entry had increased from 2 percent to 5 percent.

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Among other organizations, the National Qual-ity Forum has endorsed a range of patient-safetymeasures through its consensus process, the NewYork and Georgia hospital associations are using thepatient-safety indicators developed by the Agencyfor Healthcare Research and Quality in their im-provement efforts, the Joint Commission on Ac-creditation of Healthcare Organizations has adopt-

ed patient-safety goals as part of the accreditationprocess, and nearly all eligible hospitals are report-ing data on the quality of care through the Centerfor Medicare and Medicaid Services. Most hospitalsnow have a written policy for informing patients ortheir families of a preventable medical error. Andthe American Board of Medical Specialties has ex-panded the requirements for maintenance of boardcertification to include demonstrated competencein providing safe, high-quality care. Furthermore,recently published studies document the effective-ness of system-based changes, such as reducing thework hours of medical personnel, in reducing therate of errors.

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Congress has also joined the effort. The Houseof Representatives passed legislation in 2003, andthe Senate passed related legislation in August 2004;these bills are intended to increase the reporting ofmedical errors and problems with patient safety. Ifthe bills are reconciled, the legislation will establishgreater protections for providers that report such in-formation, as well as creating patient-safety organi-zations in the states to help analyze safety data andimplement improvements.

The ultimate purpose of all these efforts, ofcourse, is to protect the public. In our 2004 nation-al survey, one third of respondents reported person-al or family experience with medical errors, many ofthem causing serious health consequences.

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Un-fortunately, despite five years of focused attention,people do not seem to feel safer. More than half (55percent) of the respondents in our survey said thatthey are currently dissatisfied with the quality ofhealth care in this country

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— as compared with 44percent four years ago.

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In fact, 40 percent believethat the quality of health care has “gotten worse” inthe past five years, whereas only 17 percent think itis better. And half are worried about the safety oftheir medical care.

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How can we increase confidence in health care,as we continue to address safety and quality? A ma-jor obstacle is the absence of a consensus on whatspecific efforts should be the focus of safety im-provement, including how best to collect and reportinformation on the quality and safety of hospitalsand health care providers. Reaching that consensuswill be difficult for many reasons. Perhaps most


Drew E. Altman, Ph.D., Carolyn Clancy, M.D., and Robert J. Blendon, Sc.D.

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challenging is the gap between the steps identifiedas important by patient-safety experts and the viewsof health care providers. For example, according toa 2002 survey, a majority of practicing physicianssee just two approaches as very effective in reduc-ing errors: “requiring hospitals to develop systemsto avoid medical errors” (55 percent) and “increas-ing the number of hospital nurses” (51 percent).Fewer physicians agree that other proposed mea-sures would be very effective: limiting certain high-risk procedures to high-volume centers (40 percent),using only physicians trained in intensive care med-icine in hospital intensive care units (34 percent),increasing the use of computerized ordering sys-tems (23 percent), and computerizing medical rec-ords (19 percent).

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Physicians also strongly oppose public report-ing of information on medical errors — perhaps be-cause of worries about malpractice lawsuits, whichphysicians name as the top concern facing healthcare and medicine today.

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In stark contrast, 71 per-cent of the public believes that public reporting ofmedical errors by government agencies would be

very effective in reducing errors, and 7 in 10 per-sons say that such reports would tell them “a lot”about the quality of a hospital or a health plan.

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Although these challenges are real, the issue ofpatient safety may be less difficult to resolve thanmany health care issues — such as covering the un-insured or providing prescription-drug coverage— since it does not involve the sort of ideologicaland partisan differences that stall action. And al-though it will take an investment of resources totackle, we do not think it will require hundreds ofbillions of dollars, as these other issues do.

Moreover, there has already been some move-ment on a key front — the greater use of informa-tion technology. Although they offer no panacea,such technological solutions as computerized or-der-entry systems, bar coding of medications, elec-tronic prescribing, and strategies for sharing infor-mation have the potential to make care safer. Also,the interest expressed in the Health InformationTechnology Framework recently released by the De-partment of Health and Human Services could gal-vanize further action, leading to greater safety im-provements and more information for patients andproviders to use in deciding on the services patientsreceive.

However, the 2003 IOM report on data standardsfor patient safety (

Patient Safety: Achieving a New Stan-dard of Care

) makes clear that what is really neededis a culture that encourages the sharing rather thanthe hiding of errors and near misses. The principalobstacle to broader action is therefore not Congressor money but a lack of consensus among policymakers and the public, and especially among healthprofessionals themselves, on which events shouldbe publicly reported and what systemwide steps areneeded to prevent avoidable harm. Reaching con-sensus will require a national dialogue and the rec-ognition by physicians that business as usual willnot improve patient safety.

In the past five years, many promising effortshave been launched, but the task is far from com-plete. If we do not expand and accelerate current ef-forts, we can expect future surveys to reveal a persis-tent lack of confidence in the safety and quality ofthe nation’s health care system.

From the Kaiser Family Foundation, Menlo Park, Calif. (D.E.A.);the Agency for Healthcare Research and Quality, Rockville, Md.(C.C.); and the Department of Health Policy and Management,Harvard School of Public Health, Boston (R.J.B.).


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1.

Blendon RJ, DesRoches CM, Brodie M, et al. Views of prac-ticing physicians and the public on medical errors. N Engl J Med2002;347:1933-9.

2.

The Leapfrog Group Hospital Patient Safety Survey, April2003–March 2004. Washington, D.C.: Leapfrog Group, 2004.

3.

Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of elim-inating extended work shifts and reducing weekly work hours onserious medical errors in intensive care units. N Engl J Med

2004;351:1838-48.

4.

Kaiser Family Foundation, Agency for Healthcare Researchand Quality, Harvard School of Public Health. National surveyon consumers’ experiences with patient safety and quality infor-mation. Menlo Park, Calif.: Kaiser Family Foundation, July 5,2004.

5.

Gallup poll. Storrs, Conn.: Roper Center for Public OpinionResearch, September 11, 2000.

“It’s a really great case,” the neurology residentsaid. “Gerstmann’s syndrome.” I was a third-yearmedical student, and neurology was my first clini-cal rotation. The resident listed the four findingsassociated with the disorder: agraphia, right–leftdisorientation, finger agnosia, and acalculia. “Dueto a tumor in the parietal lobe,” he explained.

We entered the patient’s room. A disheveled manin a hospital gown looked at us uncertainly. Theresident had the man attempt a series of tasks andmaneuvers demonstrating all the elements of thesyndrome’s tetrad.

“What a great case,” I said as we left. The resi-dent smiled.

Internal medicine followed neurology. A cachec-tic drug user was admitted in the middle of thenight with spiking fevers. “Listen to his heart,”the intern instructed. I placed my stethoscope overthe shrunken chest. Cacophony flooded my ears.“His valves are chewed to nothing,” the intern said.It was acute bacterial endocarditis, and the internrecited some of its devastating complications:brain abscess, heart block, endarteritis. No doubt,I thought, it was a great case.

Over the course of the year, I learned that therewere subsets of great cases. Some were great puz-zles. On rounds, master clinicians with encyclope-dic knowledge would weave together seeminglyloose ends of information — threads from the his-tory, the physical examination, and laboratory tests— and form a whole cloth of diagnosis. The verybest of these great cases were called “fascinomas”— arcane diseases that tested your acumen andevoked awe at the strange forms maladies could

take. I recall a middle-aged woman with months ofheadaches supposedly due to “sinusitis” who turnedout to have histiocytosis. The resident beamed as hedescribed the multiple and subtle presentations ofthe proliferating Langerhans’ cells that eroded boneand invaded the brain.

Other cases were great because of the musculardrama they brought. In surgery, these were called“womps.” A man with a gunshot wound to the gutwas rushed into the emergency room. All handswere on deck, elbow deep in blood, putting in cath-eters, inserting an endotracheal tube, palpating thelacerated organs. A woman with a retroperitonealsarcoma that had snaked up her abdomen, penetrat-ed the diaphragm, and gripped her heart underwentan 11-hour dissection requiring teams from surgi-cal oncology, thoracic surgery, and cardiac surgery.Such cases were great because they afforded a livetour of human anatomy.

As our clinical rotations came to an end, we dis-cussed where to intern. Choosing well involved con-sidering not only the location of the hospital and itsstaff ’s commitment to teaching, but also whetherthere was “amazing pathology,” a range of diseasewide and deep enough to yield “great cases” alongwith the regular fare of internal medicine: pepticulcer disease, adult-onset diabetes, alcoholic cir-rhosis.

As a house officer, I was drawn to the specialtyof hematology because it seemed to be filled withgreat cases that came cloaked in a special beauty.Under the microscope, blood and marrow frompatients with acute promyelocytic leukemia or theSézary syndrome or thalassemia looked like won-

d o c t o r s a n d p at i e n t s

A Great CaseJerome Groopman, M.D.



Improving Patient Safety - Five years after the IOM Report

Health & Medicine

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