Authors: Linda T Kohn, Janet M Corrigan, Molla S Donaldson (editors)
This is the report that almost single-handedly brought human errors to the top of the health care agenda and kindled the patient safety movement. Commissioned by the Committee on Quality of Health Care in America, a part of the Institute of Medicine, it is the first stage of a wider quality improvement strategy. The report reviewed the extent and impact of health care errors, and produced a framework for improving patient safety. It is ‘a call to action to make health care safer for patients’ (page 5).
The report shocked health care with evidence that medical errors account for about 98,000 deaths annually in US hospitals; the 8th leading cause of death and more than the number that die from road traffic accidents, breast cancer or AIDS (page 1). It shone the light on a staggering 2% hospital adverse drug reactions rate and annual mortality of 7,000 from medication errors (page 2). The types of errors that occur and their human and financial costs are detailed in Chapter 2 and the appendices.
Not surprisingly, the report asserts that ‘the status quo is not acceptable and cannot be tolerated any longer’ (page 3). To redress the situation it attempted to set a different tone to the prevailing perception of human errors. The title, ‘To Err Is Human’, highlights the shift in focus away from individual human errors to the more important, wider system problems that facilitate errors. The preface emphasised that ‘human beings, in all lines of work, make errors’ and ‘errors can be prevented by designing systems that make it hard to do the wrong thing and easy for people to do the right thing’. Chapter 3 discusses in-depth how systems contribute to errors.
The report indicated that the flawed culture of medicine was a core problem because it ‘creates an expectation of perfection and attributes errors to carelessness or incompetence ‘ (page 21-22). This culture discourages ‘the surfacing of errors and communication about how to correct them’. The report recognises that ‘the unwillingness to share …information means that errors remain hidden and the same errors may be repeated in different organisations’ (page 23). To change this culture the report encouraged the sharing of best practices, and the wide dissemination of patient safety information.
The main recommendations of the report centred on the idea that ‘building safety into processes of care is a more effective way to reduce errors than blaming individuals‘ (page 4). It recommended the establishment and adequate funding of a Centre for Patient Safety, and the setting up of a mandatory error reporting system for serious errors, and a voluntary one for near-misses. Chapters 5 and 6 discuss the different types of error reporting systems and the legal ramifications. Chapter 7 of the report addressed minimum patient safety standards for health care organisations and medical devices, and urged the incorporation of safety in professional relicensing processes. Chapter 8 focuses on practical aspects of human factors, and extensively reviews the principles of designing safe systems and creating safe learning environments.
A discussion of progress and pitfalls 10 years after publication of ‘To Err is Human’
Although the report is about 15 years old, its findings and recommendations remain valid today. Most of the views expressed in the report are now accepted globally. The degree to which individuals are liable for errors however remains a contentious issue and this is a subject of other books.
The report is well-written, the sequence of topics excellently arranged, and the main points highlighted at every stage. The amount of detail is just right and, without unnecessary technical language, accessible to the general reader.
The report is essential reading for anyone who wants to understand the historical context of patient safety, and the major issues it embraces. It has valuable lessons for doctors and healthcare and I highly recommend it.
- Publisher, place and year: National Academy Press, Washington, 2000
- Number of chapters: 8
- Pages: 287
- ISBN: 0-309-06837-1
- Price: £27
- Rating. 5 stars