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ABSTRACT The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. Progress in addressing other hospital-acquired adverse events has been variable. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. In sum, the frequency of preventable harm remains high, and new scientific and policy approaches to address both prior and emerging risk areas are imperative. With the increasing availability of electronic data, investments must now be made in developing and testing methods to routinely and continuously measure the frequency and types of patient harm and even predict risk of harm for specific patients. This progress could lead us from a Bronze Age of rudimentary tool development to a Golden Era of vast improvement in patient safety.
The Institute of Medicine's To Err Is Human1 was transformational for patient safety. It brought the problem of medical errors into the public eye and highlighted why every health care organization in the US must consider safety as a priority. Before the report's release, many-including leaders in major health care organizations-simply did not.
The report made several major points: Errors are common, they are costly, systems-related problems cause errors, errors can be prevented, and safety can be improved.1 Important changes resulted, including a significant increase in patient safety research sponsored mainly by the Agency for Healthcare Research and Quality (AHRQ) and hospital programs focused on measurement, accreditation, and regulation.2 The number of studies to address safety gaps increased by more than 250 percent over several years,3 and many occurred in areas that had not received previous attention.
What We Have Learned
In the years since the report's publication, it has become increasingly clear that safety issues are pervasive throughout health care and that patients are frequently injured as a result of the care they receive. The...