AHRQ: One Decade after To Err Is Human

September / October 2009


Patient Safety: One Decade after To Err Is Human

Nearly 10 years ago, the news that more people die each year from medical errors in U.S. hospitals than from traffic accidents, breast cancer, or AIDS (IOM, 2000) shocked the nation. We have made much progress in building a foundation to address patient safety since the publication of the Institute of Medicine’s (IOM) report, To Err Is Human: Building a Safer Health System, but considerable work remains to ensure that patients are safe every day and in every place where they receive healthcare.

The nation’s ongoing patient safety challenge was highlighted in the annual 2008 National Healthcare Quality Report (AHRQ, 2009) released earlier this year by my agency, the Agency for Healthcare Research and Quality (AHRQ). The report notes that patient safety has actually been getting worse instead of better. For example, one in seven hospitalized Medicare patients experiences one or more adverse events, and thousands of patients develop central-line-associated blood stream infections each year.

Among the Federal and private-sector organizations working to improve patient safety, AHRQ has had a unique vantage point in this 10-year journey. Within days of the release of the IOM’s report, then-President Clinton signed into law the Healthcare Research and Quality Act of 1999. The law reauthorized AHRQ and designated it as the lead Agency in supporting Federal research in efforts to reduce medical errors.

AHRQ and others have made notable achievements in the last decade, including raising awareness of the problem and creating patient safety tools that healthcare providers have begun using to identify and address medical errors in a systematic way. Passage of the Patient Safety and Quality Improvement Act of 2005 was another highlight, along with the Act’s authorization of Patient Safety Organizations (PSOs), which encourage providers to report and share data on events adversely affecting patients. Other achievements include building a wider and deeper evidence base about the root causes of errors and creating tools for healthcare providers and organizations to address persistent patient safety problems that stem from lack of teamwork.

However, all would agree that far more work needs to be done. We know much more than we did a decade ago, but we still need to take practical steps to get more tools into the hands of providers to make it easy for them to provide the safest care possible every day. With 10 years of solid evidence at our fingertips, it’s time to take stock of past achievements and to set goals for the future.

A Systems Problem
In its report, the IOM highlighted the notion that medical harm results largely from the systemic problems rife in healthcare. The IOM laid out a clear plan for the nation to address medical errors, including:

  • Setting national goals for patient safety.
  • Developing evidence-based knowledge and understanding of errors in healthcare.
  • Calling for voluntary and mandatory reporting efforts.
  • Calling on healthcare organizations and providers to commit to patient safety improvement by providing leadership, implementing non-punitive systems for reporting and fixing errors in their organizations, incorporating proven safety principles, and establishing interdisciplinary team efforts.
  • Reducing medical errors by 50% within 5 years.

Healthcare organizations, government, professional associations, and others overall have worked diligently to meet these and other patient safety recommendations over the past decade. However, everyone has come to realize the complexity of the medical errors challenge, and we know we’re still far from the finish line.

Let me be clear: I am just as frustrated as my colleagues in the public and private sectors with our slow rate of progress in preventing and reducing medical errors. While there are many reasons why we haven’t been able to completely eliminate all errors, one prominent factor is the environment in which healthcare services are delivered. In the fragmented, paper-based healthcare system that has predominated over the past 10 years, patient safety improvement largely has been left to each hospital or provider organization to undertake — or not — on its own.

Addressing medical errors involves each organization changing its culture and systems for care delivery. It involves improving communication and teamwork — one organization or unit at a time in a healthcare system that still rewards volume and highly compensated procedures over preventive care and improving patient outcomes. Some healthcare organizations have recognized — and embarked on—improving their culture, communications, and teamwork; however, such work takes time to produce significant and lasting results.

Perhaps one of the least-appreciated reasons for the modest progress on patient safety is the nascent nature of the field itself. Prior to the IOM report, AHRQ had just $2 million to support half a dozen projects to determine best practices to improve patient safety. Congress instructed the Agency to discover the causes of preventable errors; to design, test, and evaluate evidence-based tools and solutions to reduce errors; and to disseminate those solutions broadly.

Lessons Learned, Progress Achieved
AHRQ’s late director, John Eisenberg, MD, likened the problem of medical errors to an epidemic. As he noted at the time, research is necessary to understand the magnitude of a problem, its causes, and its burden on people; evidence-based information is crucial to developing a cure.

Dr. Eisenberg and all of our colleagues knew that obtaining the proper data to understand the issue would be challenging. Existing systems for identifying and learning from patient safety events needed to be improved. Reporting systems were cumbersome and voluntary, and healthcare providers were fearful of personal liability from such reports. Work was also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.

After hosting a National Summit on Medical Errors and Patient Safety Research in September 2000, the AHRQ-led Quality Interagency Coordination (QuIC) Task Force set an agenda, which included ways to stimulate knowledge in the burgeoning patient safety field. We received broad stakeholder input to shape a wide-ranging agenda. This included supporting research to examine patient safety events in settings beyond hospitals to developing and assessing practical tools and strategies to improve patient safety. To do this, AHRQ funded $50 million in research grants, contracts, and other patient safety projects, an essential step to begin filling the gaps in the patient safety knowledge base. The Agency also started disseminating existing evidence-based best practices related to patient safety to healthcare providers.

The first round of grants and others that followed led to a more expansive evidence-based foundation that helped the Agency and its partners, from academic researchers to Federal partners such as the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention, the Department of Defense, and others, design and test tools. These tools are now available to help organizations address fundamental issues such as how to create a culture of patient safety and teamwork to help prevent and reduce medical errors. A sampling includes:

Creating a culture of safety. AHRQ’s suite of patient safety culture surveys aid hospitals, nursing homes, and medical offices in assessing, improving, and monitoring their patient safety performance (AHRQ, 2009). The tools can provide a baseline for organizations to track changes over time and evaluate the impact of patient safety interventions. Today, more than 600 hospitals share their culture survey data, allowing hospitals to compare their efforts. Meanwhile, AHRQ WebM&M, a peer-reviewed, Web-based journal on patient safety, also has helped healthcare organizations to adopt a blame-free culture and help professionals learn from one another’s mistakes.

Encouraging teamwork. TeamSTEPPS™, an evidenced-based system to improve teamwork and communication among healthcare professionals using a comprehensive set of training curricula, was released by AHRQ and the U.S. Department of Defense in 2006 (AHRQ, 2006). Culled in part from effective practices to boost team coordination among flight crews, TeamSTEPPS has been distributed to 14,000 healthcare organizations. Today, AHRQ has supported a cadre of master team trainers who help organizations implement team-based approaches to care.

Reducing healthcare-associated infections. AHRQ supported the development of a patient safety checklist proven to prevent common, costly, sometimes deadly central line-associated bloodstream infections by up to 66% (Pronovost, 2006). The intervention includes hand-washing and other practices that lead to substantial and sustained reductions in infections. Expanded use of a comprehensive toolkit containing the checklist and other tools should help hospitals meet Department of Health and Human Services Secretary Sebelius’s recent call for them to reduce such infections by 75% over 3 years.

Preventing medication errors. Blood Thinner Pills: Your Guide to Using Them Safely is designed to enhance care coordination around anticoagulant therapy. Warfarin is the second most common drug after insulin implicated in emergency room visits for adverse drug events (AHRQ, 2009).

Reducing hospital readmissions. An AHRQ toolkit helps hospitals re-engineer their discharge processes to prevent unnecessary patient readmissions. By focusing on the discharge process—the traditional weak link in hospital care—the toolkit helped reduce hospital readmission rates by nearly 30% at a busy teaching hospital in Boston (Jack, 2009).

Advances in event reporting. Event reporting and standardized data collection will soon yield crucial data, thanks to federal efforts to create Patient Safety Organizations (PSOs), which were authorized under the Patient Safety and Quality Improvement Act. The PSOs, listed by AHRQ, this year began to receive and analyze patient safety data, while working with providers to improve care without fear of legal discovery. While we can detect and document striking increases in interest and awareness of patient safety problems, documenting improved performance is far more challenging, as it can be difficult to tell increased rates of reporting from increases (or decreases) in the actual incidence of the underlying events. AHRQ is working with CMS on a system to detect quality and safety issues from patient records. This effort should enhance our ability to know whether our aspirations for providing safer care, and those of providers, match reality over time.

Supporting patient safety training. To better prepare physicians and surgeons for high-risk events, AHRQ supports several projects that assess the use of simulation technology in improving teamwork, communication, diagnostic and technical skills, safety culture, and several other hallmarks of safe care provision.

Understanding resident fatigue. AHRQ-supported research into medical resident fatigue and its connection to medical errors prompted limits in 2003 on the hours per week that medical residents could work at U.S. hospitals. An AHRQ-funded IOM report underscored why resident fatigue remains a key patient safety workforce issue (IOM, 2008).

The Road Ahead
A decade after publication of the IOM’s sentinel report, much work remains to be done to ensure that patients are safe in the U.S. healthcare system. Our accomplishments include increased awareness of the problem, the creation of an AHRQ-led knowledge base, development of useful tools, increased attention to systems approaches to reduce medical errors and healthcare-associated infections, creation of PSOs, the training of workers in safety concepts, as well as the development of event reporting systems and establishment of national data collection standards.

Going forward, protecting patients from preventable medical harm requires a continuation of the work currently underway, continued production and dissemination of evidence-based tools and solutions that make it easier for frontline healthcare workers to provide care in a coordinated and safe manner, and creation of incentives to help ensure that the right care is delivered at the right time — every time.

The time has come to update the patient safety roadmap for the next decade. A new national summit or conversation could yield a more sharply defined plan that stakes out both practical steps and goals and updates national patient safety policy.

Practical steps could involve the creation of teams within healthcare organizations that routinely examine errors and quickly address how to resolve them. Other steps could involve the widespread use of patient and family advisory councils, so patients can become better-educated consumers and bring their valuable insights to key safety improvement measures. Patients are critical partners as we strive to deliver timely, safe, effective, patient-centered care.

As we look to the decade ahead in patient safety improvement, AHRQ will continue its mission of discovering, designing, and disseminating tools and solutions that make safer patient care not just the right thing to do but also the easy thing to do. Our goal is to ensure that evidence-based patient safety practices will become routine in every healthcare setting. I am energized by the progress made to date and by the continuing commitment my fellow clinicians and health organizations have already made toward realizing this goal. I hope you are, too.

Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at George Washington School of Medicine in Washington, D.C. She may be contacted at carolyn.clancy@ahrq.hhs.gov.

Institute of Medicine. (2000). To err is human: Building a safer health system. Available at: http://www.nap.edu/catalog.php?record_id=9728. Accessed July 2009.

Agency for Healthcare Research and Quality. (2009, May). National healthcare quality report 2008. Available at: http://www.ahrq.gov/qual/qrdr08.htm. Accessed July 2009.

Agency for Healthcare Research and Quality. (2009, April). Patient safety culture surveys. Available at: http://www.ahrq.gov/qual/patientsafetyculture/. Accessed July 2009.

Agency for Healthcare Research and Quality. (2006). TeamSTEPPS curriculum tools and materials. Available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm. Accessed July 2009.

Pronovost, P., Needham, D., Berenholtz, S., et al. (2006, December 28). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732.

Agency for Healthcare Research and Quality. (2008, August). Blood thinners: Your guide to using them safely. AHRQ Publication No. 09-0086-C. Available at: http://www.ahrq.gov/consumer/btpills.htm. Accessed July 2009.

Forster, A.J., Murff, H.J., Peterson, J.F., et al. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167.

Jack, B., Chetty, V.K., Anthony, D., et al. (2009, February 3). The re-engineered hospital discharge program to decrease rehospitalization: A randomized, controlled trial, Annals of Internal Medicine, 150(3), 178-187.

Institute of Medicine. (2008, December). Resident duty hours: Enhancing sleep, supervision, and safety. Washington, DC: National Academies Press. Available at: http://www.iom.edu/?ID=60449. Accessed July 2009.