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December 03, 2009

Ten Years After "To Err Is Human"

Ten Years After sang "I'd Love to Change the World" more than ten years ago. 

Sadly, ten years after the seminal IOM report on medical errors -- To Err Is Human -- was released, we should all be singing that song, because that wake-up call has gone largely unheeded; or perhaps a better way of putting it would be to say that efforts to address the issues raised by the report have not been uniformly successful.  The Interdisciplinary Nursing Quality Research Initiative released the following observations today:

In 1999, the Institute of Medicine’s (IOM) groundbreaking “To Err Is Human” report found that as many as 98,000 people die each year from medical errors in hospitals, making medical errors a more common cause of death than motor vehicle accidents, breast cancer, or AIDS. The report estimated that these errors cost the country nearly $38 billion each year.

Ten years later, medical errors are still a widespread problem in the American health system.  More than 1.5 million Americans are sickened, injured, or killed by medication errors each year.  1.7 million Americans battle illnesses due to hospital acquired infections, 99,000 of whom die.

INQRI posted several perspectives on the topic on its blog, including an interview with BIDMC CEO and blogger Paul Levy.  Like many health care organizations across the country, BIDMC has worked to improve quality and address medical errors over the years and, in fact, was recently recognized by the Leapfrog Group as one of 45 "Leapfrog Top Hospitals" nationwide.

The information from INQRI shows that medical error morbidity and mortality is on the rise, not on the decline, despite the attention paid to this vexing issue in the decade since "To Err Is Human." 

The question remains: How can these quality issues be addressed in the context of current health reform efforts?  Where are the "best practices" that all health care providers can learn from?  Are there best practices that are easily transferable from setting to setting?  Much has been said about "bending the cost curve," but more needs to be said -- and, more importantly, done -- about taking concrete steps to improve quality by aligning incentives properly.  Payment system reform, creating new incentives for efficient and effective care delivery, ought to be closer than it is to front and center in the current health care debate.  In addition, more attention must be paid to aligning the incentives of the various payers in the health care delivery system.  For example, employment of physicians seems to be the way of the future, though some folks trying to move large systems in that direction have been burned (Exhibit A: Alegent).  Integrated delivery systems with employed physicians seem to be able to do the best at aligning incentives, though there are certainly some counterexamples out there (including BIDMC).

This is an issue that must be addressed by lawmakers, payors and the delivery system, working together -- or at least aiming in the same direction.  Thus far, we have seen only incremental progress, at best.  

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


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Enjoyed the post. Surprised that there was no reference to tort reform, ostensibly the mechanism that deters negligence and thereby increases medical quality. I agree that we need processes and a culture that will expose error and misadventures so that we can do better. The current medical liability system is a potent obstacle to achieving the important objectives that you outlined. To understand why conscientious physicians loathe the current system, see under Legal Quality. Physicians are ready to work for the public interest. Are trial attorneys prepared to make this commitment?

Michael - I appreciate your desire to see tort reform move forward on the national agenda (though reasonable minds may differ on this one). However, I do not see the connection between tort reform (and its anticipated effects) on the one hand, and a reduction of medical errors on the other hand (unless you are suggesting that defensive medicine costs may be redirected to better-designed quality incentives). If anything, one would think that defensive medicine yields relatively error-free, if expensive, medicine. Again, the IOM figures and the "ten years after" reality check seem to indicate that little, if any, progress has been made in reducing the incidence of medical errors, despite our collective focus on the issue.

Thank you David for your comment. I mentioned tort reform as I expected that it would have been included as a quality control mechanism, particularly on a legal blog. Indeed, many lawyers whom I have discussed this issue with make this very argument, which I dispute. I have made the point on my blog, that you suggested, that the tens of billions of dollars being spent defensively could be channeled into the health care system proper. Respectfully, I challenge your point that defensive medicine is 'error-free'. It is more than just a waste of a ton of money. It creates cascades of medical chaos as each defensive test begets another. For example, the unneeded CAT scan shows some tiny, irrelevant lesion in the lung. Now, a pulmonologist will see the patient and will order scans over the next 2 yrs to assure it is not growing. Lots of radiation for the patient. Sometimes, biopies or even surgeries are advised for these innocent lesions that should have never been discovered in the first place. Obviously, any invasive test has direct risks of medical complications. This hypothetical scenario is extremely common in medical practice. Defensive medicine costss billions, generates enormous unnecessary anxiety for patients and families and has risks of harm.

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