In 1999, the Institute of Medicine published their landmark report "To Err is Human": Building a safer healthcare system. And what was so amazing about this particular report was the first time it outlined the extent of preventable harm in our healthcare system. And in fact, highlighted that between 44,000 and 98,000 people died every year due to preventable harm in hospitals. What can get lost in the statistics of preventable harm are the stories of each of the individuals that have died. The loss to their loved ones and to their communities often go unheard. Pictured here on your left is Josie King, an 18-month-old little girl who died of dehydration and septic shock from a hospital-acquired infection here at Johns Hopkins hospital in 2001. How could this occur at one of the top institutions in the United States? It was a result of a complete breakdown of our health care system. Josie died because communication broke down between teams. She died because her parents repeated pleas that her daughter was thirsty were not heard. Pictured here on your right is another story preventable harm which includes Ellen Roche. Ellen was a 24-year-old Baltimore resident who loved animals and wanted to become a veterinarian. In 2001, she was a healthy volunteer from asthma study at Johns Hopkins Baby Medical Center that would measure how healthy lungs respond to a chemical irritant which was designed to simulate asthmatic conditions. Roche developed a dry cough and needed to be admitted to the intensive care unit the day after she inhaled that chemical. She died of organ failure about one month later. In addition to all those preventable deaths, there's an enormous cost to society. Costs each year from preventable harm range somewhere between $17 and $29 billion for the United States. These are a result of additional care necessitated by error, lost income and household productivity, and disability from the patients suffer. In addition to that, patients take home physical and psychological discomfort, there's lost trust in our health care system, and there's decreased satisfaction from our patients. They expect more from us when they come into the hospital than to be harmed. For healthcare workers, this really results in decreased satisfaction, and frustration and loss of morale. They go into healthcare to help people and they end up causing preventable harm to their patients. And finally to our society, there's loss worker productivity, there's reduced school attendance by children, and there's lower levels of population health status. When you look at the different types of preventable harm in this report, the areas where preventable harm is most likely to occur are in intensive care units, in ORs, and in emergency departments. And the types of errors that they see are adverse drug events, improper blood transfusions, surgical injuries, wrong-site surgeries, suicides while in the hospital, restraint-related injuries or deaths, falls, burns, pressure ulcers and mistaken patient identity. All of these are caused by a breakdown in complex systems within our healthcare system. One of the things the Institute of Medicine report was able to do was point out that a majority of medical errors do not result from individual recklessness or the actions of particular groups, but instead are errors that are caused by our faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them. And so, this really caused a shift in how we handle mistakes from one where we shame and blame of our healthcare workers to a recognition that we were just a part of a broader system that was in fact broken, that was contributing to these mistakes. So, this report outlined four strategies for improvement. First, we needed to establish a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety. Next, we needed to identify and learn from errors by developing nationwide public mandatory reporting systems and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems. Third, we needed to raise performance standards and expectations for improvement in patient safety. The actions of oversight organizations, professional groups and group purchasers of health care. So, essentially, we needed to all come together to really understand and set performance standards and expectations so that we can work together to reduce preventable harm. And finally, we needed to implement safety systems in health care organizations to ensure safe practices at the delivery level. So, in summary, the Institute of Medicine report "To Err is Human": Building a safer healthcare system, was the landmark paper in patient safety which transitioned patients' safety from being something no one thinks about to something everyone in healthcare thinks about. To highlight this, Stelfox Henal in 2006 published this paper looking at patient safety publications in Medline and found that in the five years before, "To Err is Human" there was 59 patient safety articles per 100,000 Medline publications, and in the five years after the Institute of Medicine report, there was 164 publications per 100,000 Medline publications which was a statistically significant increase in patients 80 publications. We believe that was a result of this report.
