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Previously published at www.cmaj.ca
Alexander Pope, poet of the Enlightenment, lent a famous line from his 1711 treatise An Essay on Criticism to the US Institutes of Medicine's report on patient safety: To Err is Human.1 The remainder of the line, "to forgive divine," would have further reinforced the report's message. Those who made mistakes should neither be blamed nor punished, it argues, instead, to look at the system.
The institute's 1999 report was both a tipping and a turning point: It revealed that there were an estimated 100 000 preventable patient deaths a year in the United States. In Canada, researchers later estimated there were 70 000 preventable adverse events annually in hospitalized patients and preventable mortalities in the range of 9000 to 24 000.2 The magnitude of the problem was unmasked and the new century ushered in an era of openness. The dramatic change that occurred in removing the focus from individuals led to closer examination of health care systems and how they fail us.
The decade that followed perhaps exceeded the wildest expectations of the pioneers of the modern patient-safety movement. Studies throughout the world confirmed that the US had it right: About 10% of all patients entering hospitals suffer an adverse event and significant...