The Institute of Medicine Report on Medical Errors: Misunderstanding Can Do Harm

Quality of Health Care in America Committee*

In This Article

A National Effort Is Needed

The IOM called on all sectors of the health establishment to make patient safety a priority concern. While the key systems changes that will improve patient safety must occur in hospitals and other healthcare organizations where care is actually delivered, professional societies, specialty boards, regulatory agencies, and purchasers all must play a role. Encouragingly, in the few months since the report was issued, many of these organizations have announced their commitment and have begun to make changes.

The 50% reduction that IOM called for is a "stretch goal" -- but achievable if healthcare organizations were to implement all of the practices we already know will improve safety -- and if hospitals were to make safety a priority by creating nonpunitive environments where people are free to report and examine their errors and remedy the systems failures. While some may say it won't happen, it has already begun in many places. We are on the ascending limb of the adoption curve of safety practices.

Calls for purchasers and insurers to step up to the plate to pay for safety changes are appropriate and welcome. Some have already indicated their willingness to do so.[30] However, hospitals need not wait for payers. Traditionally, they have always found ways to pay for capital equipment they thought was essential; few forgo having a new MRI, for example, or the latest percutaneous transluminal coronary angioplasty stents, when their doctors call for them. As safety is increasingly recognized as an important corporate objective, the money may be found. There are also convincing data about the cost-effectiveness of safety measures. Computerized physician order entry systems have been shown to reduce adverse drug events by more than 50%, thus generating substantial savings in healthcare expenditures.[31,32,33]

Finally, with regard to malpractice, some have called the IOM to task for not addressing the "dead weight of a litigation system that induces secrecy and silence."[4] The IOM report specifically notes the deleterious effect of the risk of litigation and its deterrent effect on reporting. It articulates the need to "change the legal environment in which health care organizations and providers operate." The report goes on to suggest that enterprise liability and no-fault compensation might produce a more conducive legal environment and notes that "the issue merits further analysis."

But malpractice concerns should not, and must not, be a barrier to progress in improving patient safety. Indeed, in addition to reducing accidental injuries due to errors, one of the most important things hospitals can do right now to reduce liability is to take steps to improve patient safety, thereby decreasing the occurrence of serious AEs. Some organizations are making progress even in today's environment.[34]

The time for a serious effort to improve safety in healthcare has come at last. Throughout this nation, healthcare organizations are re-examining what they do, and multidisciplinary teams in many hospitals are redesigning their work and their environments to make it harder for mistakes to happen. Recognizing that errors come from faulty systems, not from faulty people, has been an immensely empowering concept. We have just scratched the surface of its possibilities for improving safety for our patients. We have much to do. We should celebrate our successes, be clear-eyed about our failures, and get on with the job of improvement.