To Err Is Human (report)

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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. [1]

Patient safety

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.

Alzheimers disease progressive, neurodegenerative disease characterized by memory loss

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 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". [2]

The report has been called "groundbreaking" for suggesting that 2-4% of all deaths in the United States are caused by medical errors. [3]

The report is credited with raising awareness of the extent to which medical error was a problem. [4] The report described that errors were not rare or isolated, and only by broad planning could they be diminished. [4] 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. [4]


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. [5]

Bill Clinton 42nd president of the United States

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.

Follow up

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.

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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.

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<i>Crossing the Quality Chasm</i> book by Institute of Medicine

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Patient Safety and Quality Improvement Act

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.

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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.


  1. Mokdad, Ali; James Marks; Donna Stroup; Julie Gerberding (2000). "Actual Causes of Death in the United States, 2000" (PDF). JAMA. Journal of the American Medical Association. 291 (10): 1238–45. doi:10.1001/jama.291.10.1238. PMID   15010446 . Retrieved 2007-04-10.
  2. Mahn-DiNicola, Vicky A (2004). "Changing competencies in health care professions". Nurse Leader. 2 (1): 38–43. doi:10.1016/j.mnl.2003.11.003. ISSN   1541-4612.
  3. Ballweg, Ruth, ed. (2013). "Prevention of Medical Errors". Physician assistant : a guide to clinical practice (5th ed.). Philadelphia, PA: Elsevier/Saunders. ISBN   978-1455706570.
  4. 1 2 3 Yoder-Wise, [edited by] Patricia S. (2014). Leading and managing in nursing (5th ed., rev. reprint. ed.). St. Louis, Mo.: Elsevier Mosby. p. 26. ISBN   978-0323241830.
  5. "Medical errors and the Institute of Medicine (IOM) - Patient safety". 2014. Retrieved 25 June 2014.