Why It Matters
Fifteen years after the release of landmark To Err Is Human report, health care it still not as safe as it should be for all patients.
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15 Years after To Err Is Human: The Status of Patient Safety in the US and the UK

By Frank Federico | Sunday, December 6, 2015

Fifteen years after the release of the IOM’s landmark report, To Err Is Human: Building a Safer Health System, two new reports highlight the progress we’ve made and also argue that we still have far to go to make care as safe as it should be for all patients. IHI Vice President Frank Federico was a member of the expert panel that contributed to a new National Patient Safety Foundation report. In this blog post, he provides an overview of this report and another from the UK’s Health Foundation.


 Frank Federico (left) teaching at IHI's Patient Safety Executive Development Program

Fifteen years after the release of the IOM’s landmark report, To Err Is Human: Building a Safer Health System, two new reports highlight the progress we’ve made.

They also argue that we still have far to go to make care as safe as it should be for all patients. I’m not surprised — having seen the care my mother received in the months before she died.

In most cases, my mother received the right care from a dedicated team of doctors, nurses, and allied health professionals. But considering all the care my mother needed — in a variety of settings from a wide range of providers — I came to see how difficult it is to deliver safe care in today’s complex health care environment.

The Report from the UK: Many Systems Not Designed with Safety in Mind

The Health Foundation in the UK recently published Continuous Improvement of Patient Safety: The Case for Change in the NHS. Those of us outside Britain ignore the hard-won lessons here at our peril — or, more accurately, that of our patients. Much of what author John Illingworth, Policy Manager at the Health Foundation, describes is all too familiar to me as an American who has traveled extensively, because the challenges are universal.

The paper reports on the status of patient safety in Britain and describes the difficult challenge of continually trying to improve it. Illingsworth states that although there have been many changes tested and implemented to improve safety, many systems are not designed with patient safety in mind. “It is only the skill and resilience of health care professionals,” he asserts, “that prevents many more episodes of harm.” However, he also argues, we cannot adequately address system problems through individual efforts or local improvement initiatives alone.

LEARN MORE: IHI Patient Safety Congress

The first part of the report focuses on the case for change. “As with other safety-critical industries,” Illingworth contends, “it is imperative that when failures do occur, lessons are learned and action is taken to prevent the same issues reoccurring.” This notion of a continuous learning system is key element of IHI’s Framework for Safety.

The second part of the report focuses on safety and improvement in practice. One of the key lessons is that while many resources have rightly been invested in reporting and measurement systems that help us learn from the past, we must put as much effort into looking forward and anticipating risks. In other words, attention spent understanding what has already happened should not blind us to the future. It would be like driving your car while constantly looking into the rearview mirror.

The report ends with a vision of an effective system for safety, which includes:

  1. Measurement and monitoring
  2. Improvement and learning
  3. Engagement and culture
  4. Strategy and accountability

The National Patient Safety Foundation (NPSF) Report: Not Enough Change Since To Err Is Human

A committee co-chaired by Dr. Don Berwick and Dr. Kavek Shajania issued the NPSF’s Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Similar to the Health Foundation’s assessment of patient safety in the UK, the NPSF report states that — despite some improvement in patient safety in the United States — the pace and scale of improvement has been disappointingly slow and limited. Patients continue to experience harm when interacting with the health care system and, consequently, much more needs to be done. Like the Health Foundation, NPSF also notes that the problem of making health care safer is far more complex than initially understood.

NPSFThe NPSF report includes eight recommendations (see infographic, right):

  1. Ensure that leaders establish and sustain a safety culture.
  2. Create a centralized and coordinated approach to patient safety.
  3. Create a common set of safety metrics that reflect meaningful outcomes.
  4. Prioritize funding for research in patient safety and implementation science.
  5. Address safety across the entire care continuum.
  6. Support the health care workforce.
  7. Partner with patients and families for the safest care.
  8. Ensure that technology is safe and optimized to improve patient safety.

None of the recommendations in either report is new, but are we finally prepared to put them into action consistently?

These ideas are not easy to implement. My years in health care taught me this lesson, but watching my mother’s care as she interacted with various health systems confirmed it.

Each day, I witnessed issues similar to those described in the report, including a lack of equipment, poor staffing, missed or delayed medications, flawed handovers, and miscommunication. These problems threatened to undermine — and sometimes actually negate — the otherwise great caregiving. Although the staff addressed the most obvious hazards, they had not developed a process to learn about and address the risks that popped up every day or to anticipate problems before they occurred.

To help put the lessons outlined in both of these reports into practice, IHI will explore them in more detail in the coming months.

In the meantime, what do you think of the Health Foundation and NPSF recommendations? Share your thoughts and ideas in the User Comments section below.

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