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Practice Implications of Keeping Patients Safe

Improving patient safety and other dimensions of health care quality requires change at all four levels of the health care system: (1) the experience of patients during their interactions with individual clinicians; (2) the functioning of small units (microsystems) of care delivery such as surgical teams or nursing units; (3) the practices of organizations that house the microsystems; and (4) the environments of policy, payment, regulation, accreditation, and other factors external to the actual delivery of care that shape the context in which health care organizations deliver care. Several groundbreaking Institute of Medicine (IOM) reports have spurred substantial actions at each of these levels to bring about improvements in patient safety and overall quality. These IOM reports began as the product of the unique Committee on the Quality of Health Care in America created by the IOM in 1998 in response to the accumulating number of studies documenting that the way in which health care has been delivered has not kept pace with the advances in medical technology and our growing knowledge about diseases and how to effectively treat them. The committee’s first report, To Err Is Human, was stunning. This report documented that not only was health care often of poor quality, it was actually unsafe. The report said that between 44,000 and 98,000 deaths every year (more than deaths from breast cancer, AIDS, or motor vehicle accidents) were caused by problems in the way the health care system was designed, not from “bad” doctors, nurses, or other health care workers. The report’s message and recommendations for building safer systems of care delivery across the entire U.S. health care system primarily addressed the changes needed at the fourth level of the health care system—where policy, payment, regulation, accreditation, and similar external factors shape the delivery of health care. Within weeks of the report’s release, the Senate Committee on Appropriations began hearings on medical errors and patient safety. As a result of those hearings, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to lead a national effort to combat medical errors and improve patient safety. AHRQ subsequently established a research and demonstration program to fund research to determine the causes of medical errors and to develop models that minimize the frequency and severity of errors; mechanisms that encourage reporting, prompt review, and corrective action; and methods to minimize paperwork.