The Institute of Medicine (IOM) released their landmark report, To Err Is Human, in 1999 and reported that as many as 98,000 people die in hospitals every year as a result of preventable medical errors. Headlines at the time read: “Medical mistakes 8th top killer,” “Medical errors blamed for many deaths,” and “Experts say better quality controls might save countless lives.” The public and the healthcare industry were completely engaged with the report at the time.
One of the main conclusions of the report was that most errors are not a result of incompetent healthcare professionals but rather a result of bad systems and processes that fail to prevent error. A comprehensive strategy for reducing preventable medical errors was included and a goal was set to reduce the errors by 50% over 5 years.
So how are we doing? Unfortunately, we have not come close to achieving the IOM's goal. In 2013, there were about 400,000 deaths from preventable medical errors. And just this year the American Nurses Association launched a national campaign focusing on a culture of safety. This national campaign and important 2016 National Nurses Week message comes to us more than 16 years after the 1999 IOM report. To have a culture of safety there must be transparency, mutual trust, accountability, and an environment that promotes learning from errors. A culture of safety empowers individuals to speak up when there is a potential safety breach without fear of repercussions.
Every single employee in the healthcare industry and every consumer of healthcare has to embrace the message that a culture of safety starts with them! Further, the IOM report provided us with a four-tiered roadmap to success. But we are still falling way short of that initial goal and we have to investigate why. We have to take advantage of the resources that are available. Every one of us can find something on the Agency for Healthcare Research and Quality and IOM websites to make our own practice safer. Every one of us has to be diligent in our work to identify safety vulnerabilities, and together staff and organizational leadership can put systems and processes in place to minimize those vulnerabilities. Healthcare teams need to ask, “Who is the next patient that we could harm?” and work together to prevent it.
We need to hold each other accountable for safety. We have to understand the science of safety and human factors. To err IS human; we all need to understand and own that. Once we do, we can collaboratively create a consistent culture of safety across the healthcare continuum.
AnneMarie Palatnik, MSN, APN, ACNS-BC
Barnsteiner J. Teaching the culture of safety. Online J Issues Nurs
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.
Institute of Medicine. To Err Is Human: Building a Safer Health System
. Washington, DC: National Academy Press; 2000.
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf
Julianne M. Nurses create a culture of patient safety: it takes more than projects. Online J Issues Nurs
Sitterding M. Overview and summary: creating a culture of safety: the next steps. Online J Issues Nurs