The Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century
, describes the immense divide between what we know to be good health care and the health care people actually receive. Of the report’s "Aims for Improvement," number one is safety. Patients should not be harmed by the care that is intended to help them. The ancient maxim "First, do no harm" has guided physicians for millennia, but it does not penetrate deep enough into the health care system: Health care must be fundamentally redesigned to make safety a design function rather than the individual health care provider’s responsibility. (In the words of Donald M. Berwick, MD, MPP, former President and Chief Executive Officer of the Institute for Healthcare Improvement and one of the Chasm
report’s architects, "You can’t make planes safer by asking pilots to please not crash.")
The statistics on this front are staggering. Two years before publishing Crossing the Quality Chasm, the Institute of Medicine reported that in the United States alone, an estimated 44,000 to 98,000 people die annually from medical mistakes. Current estimates from the Agency for Healthcare Research and Quality place medical errors as the eighth leading cause of death in the US. That makes medicine deadlier than highway accidents, breast cancer, or AIDS. Seven out of every 100 hospital patients are subjected to a serious or potentially serious medication error during their admission. The mistakes — the adverse events — range from the harmless, like misplacing patient records, to the harmful, like administering the wrong drug. No matter what the degree of harm, most adverse events are symptoms not of bad character or incompetence on the part of the individual care provider, but of a fundamentally faulty system.
To fundamentally change the system, we need a new kind of environment, one where noticing and learning from mistakes is not only acceptable but expected. A culture of safety is the foundation on which successful safety efforts are built. Punishment does not improve safety; creating better systems does.
System changes can be as basic as simplifying forms, reorganizing medication storage and delivery procedures, adding safety responsibilities to staff job descriptions, or giving patients brochures about medication safety. Or they can be as expansive as adopting electronic medical records and computerized order entry capabilities, involving patients in safety initiatives, or abolishing punishments for adverse events. Many organizations are beginning to make dramatic leaps in patient safety by taking on these challenges: Some have reduced their number of adverse drug events by 75 percent, and others have improved medication reconciliation at transition points by 75 percent. The results these organizations achieved are remarkable, and they demonstrate the great potential for positive change in our health care system.