RESPONSE TO MEDICAL ERRORS

In 2000, the Institute of Medicine (IOM) published a book titled, To Err Is Human: Building a Safer Health System.  Alarming statistics were revealed within this text, referencing that an estimated 98,000 people die annually in the U.S. from medical errors occurring in hospitals.  Medical errors were referenced as the third leading cause of death in the U.S.  Within the text, the IOM outlined a national agenda for reducing medical errors and improving patient safety through the design of a safer health system.  The IOM made broad range recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and the development of effective systems at the level of direct patient care. The text reinforced that the problem is not bad people in health care, rather good people working in bad systems that need to be made safer.

In 2016, Johns Hopkins patient safety experts calculated that more than 250,000 deaths annually were due to medical error in the U.S.

The U.S. DOH and Human Services, along with the Agency for Health Care Research and Quality (AHRQ) published a November, 2021 U.S. DOH report referencing strategies to reduce medical errors.

In response to the increase in medical errors, the U.S. DOH and Human Services, along with AHRQ, have proposed the following defense strategies:

• Monitor risk by using analytical approaches to patient safety research, measurement, and practice improvement.
• Monitor patient safety problems by increasing the use of research methodologies
• Implement evidence-based practice in real-world settings supported by useful tools and infrastructure.
• Utilization of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.

Key Highlights:

• The report referenced the importance of developing learning health systems as such healthcare systems are better able to support the integration of the most current evidence to improve care.
• The report referenced the importance of analyzing healthcare data, specific to procedures and patient outcomes to evaluate safe practices and opportunities for improvement.
• The development of a learning healthcare system requires a culture of safety and a shared mental model to drive improvement in clinical practice that is outcomes based. 

To view full report, see the AHRQ.gov link below:

AHRQ.gov: https://psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality

HealthcareITnews.com: https://www.healthcareitnews.com/news/feds-point-learning-health-system-key-patient-safety

Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.https://doi.org/10.17226/9728.

John Hopkins Medicine: https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us