To Err Is Human: Building a Safer Health System

Experts estimate that as many as 98 000 people die in any given year from medical errors that occur in hospitals. Thats more than die from motor vehicle accidents breast cancer or AIDSthree causes that receive far more public attention. Indeed more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy and medical error easily rises to the top ranks of urgent widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequencebut not by pointing fingers at caring health care professionals who make honest mistakes. After all to err is human. Instead this book sets forth a national agendawith state and local implicationsfor reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it given many patients expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation regulation and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorswhich begs the question "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts the Institute of Medicine presents wide-ranging recommendations for improving patient safety in the areas of leadership improved data collection and analysis and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careit is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal state and local health policy makers and regulators health professional licensing officials hospital administrators medical educators and students health caregivers health journalists patient advocatesas well as patients themselves. First in a series of publications from the Quality of Health Care in America a project initiated by the Institute of Medicine