To Err Is Human: Building a Safer Health System is a report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors. The push for patient safety that followed its release continues. The report was based upon analysis of multiple studies by a variety of organizations and concluded that between 44,000 to 98,000 people die each year as a result of preventable medical errors. For comparison, fewer than 50,000 people died of Alzheimer's disease and 17,000 died of illicit drug use in the same year.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting, and analysis of medical error that often leads to adverse effects. The frequency and magnitude of avoidable adverse events experienced by patients was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety. The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers and consumers, enhancing error reporting systems, and developing new economic incentives.
Alzheimer's disease (AD), also referred to simply as Alzheimer's, is a chronic neurodegenerative disease that usually starts slowly and gradually worsens over time. It is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, not managing self care, and behavioural issues. As a person's condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Although the speed of progression can vary, the typical life expectancy following diagnosis is three to nine years.
The report called for a comprehensive effort by health care providers, government, consumers, and others. Claiming knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next five years. Though not currently quantified, as of 2007 [update] this ambitious goal has yet to be met.
The report "brought the issues of medical error and patient safety to the forefront of national concern".
The report has been called "groundbreaking" for suggesting that 2-4% of all deaths in the United States are caused by medical errors.
The report is credited with raising awareness of the extent to which medical error was a problem.The report described that errors were not rare or isolated, and only by broad planning could they be diminished. It also described that most errors are systemic in the health care industry, and cannot be resolved at the level of individual health care providers.
The report had a huge impact on management of health care.
As a result of the report President Bill Clinton signed Senate bill 580, the Healthcare Research and Quality Act of 1999, which renamed The Agency for Health Care Policy and Research to Agency for Healthcare Research and Quality to indicate a change in focus. The bill also funded projects through that organization.
William Jefferson Clinton is an American politician who served as the 42nd president of the United States from 1993 to 2001. Prior to the presidency, he was the governor of Arkansas from 1979 to 1981, and again from 1983 to 1992, and the attorney general of Arkansas from 1977 to 1979. A member of the Democratic Party, Clinton was ideologically a New Democrat and many of his policies reflected a centrist "Third Way" political philosophy.
The Agency for Healthcare Research and Quality is 1 of 12 agencies within the United States Department of Health and Human Services (HHS). The agency is headquartered in North Bethesda, Maryland, a suburb of Washington, D.C. (with a. It was established as the Agency for Health Care Policy and Research as a constituent unit of the Public Health Service under the Omnibus Budget Reconciliation Act of 1989, December 19, 1989, to enhance the quality, appropriateness, and effectiveness of health care services and access to care by conducting and supporting research, demonstration projects, and evaluations; developing guidelines; and disseminating information on health care services and delivery systems.
The report was followed in 2001 by another widely cited Institute of Medicine report, "Crossing the Quality Chasm," which furthers many points from the original study. Both are widely referenced. "To Err Is Human" was the inspiration for the Institute for Healthcare Improvement's 100,000 Lives Campaign , which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals.
Emergency medicine, also known as accident and emergency medicine, is the medical specialty concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians care for unscheduled and undifferentiated patients of all ages. As first-line providers, their primary responsibility is to initiate resuscitation and stabilization and to start investigations and interventions to diagnose and treat illnesses in the acute phase. Emergency physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units, but may also work in primary care settings such as urgent care clinics. Sub-specializations of emergency medicine include disaster medicine, medical toxicology, ultrasonography, critical care medicine, hyperbaric medicine, sports medicine, palliative care, or aerospace medicine.
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need. Patients commonly receive primary care from professionals such as a primary care physician, a nurse practitioner, or a physician assistant. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer, or a Ayurvedic or other traditional medicine professional. Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.
A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Globally, it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment; this is an increase from 94,000 in 1990. However, a 2016 study of the number of deaths that were a result of medical error in the U.S. placed the yearly death rate in the U.S. alone at 251,454 deaths, which suggests that the 2013 global estimation may not be accurate.
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care.
In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs.
A Regional Health Information Organization, also called a Health Information Exchange Organization, is a multistakeholder organization created to facilitate a health information exchange (HIE) – the transfer of healthcare information electronically across organizations – among stakeholders of that region's healthcare system. The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. RHIOs are also intended to support secondary use of clinical data for research as well as institution/provider quality assessment and improvement. RHIO stakeholders include smaller clinics, hospitals, medical societies, major employers and payers.
A patient safety organization (PSO) is a group, institution or association that improves medical care by reducing medical errors. In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable adverse health care events. In the United States, the Institute of Medicine report (1999) called for a broad national effort to include the establishment of patient safety centers, expanded reporting of adverse events and development of safety programs in health care organizations. The organizations that developed ranged from governmental to private, and some founded by industry, professional or consumer groups. Common functions of patient safety organizations are data collection and analysis, reporting, education, funding and advocacy.
Christine K. Cassel is a leading expert in geriatric medicine, medical ethics and quality of care. She is Planning Dean of the new Kaiser Permanente School of Medicine. Unit IL March 2016, she was President and CEO of the National Quality Forum. Previously, Cassel served as President and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation.
Clinical Nurse Leader (CNL) is a relatively new nursing role that was developed in the United States to prepare highly skilled nurses focused on the improvement of quality and safety outcomes for patients or patient populations. The CNL is a registered nurse, with a Master of Science in Nursing who has completed advanced nursing coursework, including classes in pathophysiology, clinical assessment, finance management, epidemiology, healthcare systems leadership, clinical informatics, and pharmacology. CNLs are healthcare systems specialists that oversee patient care coordination, assess health risks, develop quality improvement strategies, facilitate team communication, and implement evidence-based solutions at the unit (microsystem) level. CNLs often work with clinical nurse specialists to help plan and coordinate complex patient care.
The philosophy of healthcare is the study of the ethics, processes, and people which constitute the maintenance of health for human beings. For the most part, however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societal institution of healthcare can be seen as a necessary phenomenon of human civilization whereby an individual continually seeks to improve, mend, and alter the overall nature and quality of their life. This perennial concern is especially prominent in modern political liberalism, wherein health has been understood as the foundational good necessary for public life.
Donald M. Berwick is a former Administrator of the Centers for Medicare and Medicaid Services (CMS). Prior to his work in the administration, he was President and Chief Executive Officer of the Institute for Healthcare Improvement a not-for-profit organization.
Crossing the Quality Chasm: A New Health System for the 21st Century is report on health care quality in the United States published by the Institute of Medicine (IOM) on March 1, 2001. A follow-up to the frequently cited 1999 IOM patient safety report To Err Is Human: Building a Safer Health System, Crossing the Quality Chasm advocates for a fundamental redesign of the U.S. health care system.
Fatal Care: Survive in the U.S. Health System is a book about preventable medical errors written by Sanjaya Kumar, president and chief medical officer of Quantros, Milpitas, California. Fatal Care was published in April 2008 by IGI Publishing, Minneapolis, Minnesota.
Health information technology is information technology applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on an often-cited 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands – the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system. According to a 2006 report by the Agency for Healthcare Research and Quality, broad and consistent utilization of HIT will:
ECRI Institute is an independent nonprofit organization authority on the medical practices and products that provide the safest, most cost-effective care.
The Patient Safety and Quality Improvement Act of 2005 (PSQIA): Pub.L. 109–41, 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety organizations and a national patient safety database. To encourage reporting and broad discussion of adverse events, near misses, and dangerous conditions, it also established privilege and confidentiality protections for Patient Safety Work Product. The PSQIA was introduced by Sen. Jim Jeffords [I-VT]. It passed in the Senate July 21, 2005 by unanimous consent, and passed the House of Representatives on July 27, 2005 with 428 Ayes, 3 Nays, and 2 Present/Not Voting.
Health care in the United States is provided by many distinct organizations. Health care facilities are largely owned and operated by private sector businesses. 58% of US community hospitals are non-profit, 21% are government owned, and 21% are for-profit. According to the World Health Organization (WHO), the United States spent $9,403 on health care per capita, and 17.1% on health care as percentage of its GDP in 2014. Healthcare coverage is provided through a combination of private health insurance and public health coverage. The United States does not have a universal healthcare program, unlike other advanced industrialized countries.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, to cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.