Cover image for To err is human : building a safer health system
Title:
To err is human : building a safer health system
Author:
Kohn, Linda T.
Publication Information:
Washington, D.C. : National Academy Press, [2000]

©2000
Physical Description:
xxi, 287 pages : illustrations ; 24 cm
Language:
English
ISBN:
9780309068376
Format :
Book

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Call Number
Material Type
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Status
Central Library R729.8 .T6 2000 Adult Non-Fiction Non-Fiction Area
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Summary

Summary

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three 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 consequence--but 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 agenda--with state and local implications--for 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 errors--which 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 care--it 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 advocates--as 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


Table of Contents

Executive Summaryp. 1
1 A Comprehensive Approach to Improving Patient Safetyp. 17
Patient Safety: A Critical Component of Qualityp. 18
Organization of the Reportp. 21
2 Errors in Health Care: A Leading Cause of Death and Injuryp. 26
Introductionp. 27
How Frequently Do Errors Occur?p. 29
Factors That Contribute to Errorsp. 35
The Cost of Errorsp. 40
Public Perceptions of Safetyp. 42
3 Why Do Errors Happen?p. 49
Why Do Accidents Happen?p. 51
Are Some Types of Systems More Prone to Accidents?p. 58
Research on Human Factorsp. 63
Summaryp. 65
4 Building Leadership and Knowledge for Patient Safetyp. 69
Recommendationsp. 69
Why a Center for Patient Safety Is Neededp. 70
How Other Industries Have Become Saferp. 71
Options for Establishing a Center for Patient Safetyp. 75
Functions of the Center for Patient Safetyp. 78
Resources Required for a Center for Patient Safetyp. 82
5 Error Reporting Systemsp. 86
Recommendationsp. 87
Review of Existing Reporting Systems in Health Carep. 90
Discussion of Committee Recommendationsp. 101
6 Protecting Voluntary Reporting Systems From Legal Discoveryp. 109
Recommendationp. 111
Introductionp. 112
The Basic Law of Evidence and Discoverability of Error-Related Informationp. 113
Legal Protections Against Discovery of Information About Errorsp. 117
Statutory Protections Specific to Particular Reporting Systemsp. 121
Practical Protections Against the Discovery of Data on Errorsp. 124
Summaryp. 127
7 Setting Performance Standards and Expectations for Patient Safetyp. 132
Recommendationsp. 133
Current Approaches for Setting Standards in Health Carep. 136
Performance Standards and Expectations for Health Care Organizationsp. 137
Standards for Health Professionalsp. 141
Standards for Drugs and Devicesp. 148
Summaryp. 151
8 Creating Safety Systems in Health Care Organizationsp. 155
Recommendationsp. 156
Introductionp. 158
Key Safety Design Conceptsp. 162
Principles for the Design of Safety Systems in Health Care Organizationsp. 165
Medication Safetyp. 182
Summaryp. 197
Appendixes
A Background and Methodologyp. 205
B Glossary and Acronymsp. 210
C Literature Summaryp. 215
D Characteristics of State Adverse Event Reporting Systemsp. 254
E Safety Activities in Health Care Organizationsp. 266
Indexp. 273

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