Q&A: The Impact of To Err is Human at 20

By Brian Ward

November 29 marks the 20th anniversary of the Institute of Medicine report To Err is Human, which flipped conventional ideas about medical errors and prevention on their head and started the modern patient safety movement. Since the report’s initial claim that as many as 98,000 people die annually from medical errors, there have been major strides in changing healthcare organization’s systemic problem, workplace cultures, and improvement processes.

Patricia McGaffigan, RN, MS, CPPS, vice president of safety programs at the Institute for Healthcare Improvement (IHI), spoke with us about how To Err is Human changed patient safety.

Q: What was the impact of To Err is Human when it came out? Why was it so groundbreaking?

McGaffigan: There had been other papers and stories related to adverse outcomes prior to the publication of To Err is Human [about patients] suffering severe injury as a result of care that should have healed and treated them. However, To Err is Human was published by an incredibly prestigious organization, it had selected a panel of highly credible experts, and they attributed a number of lives that lost each year from preventable healthcare harm. If you go back and ask what people remember about the report, I think they’ll tell you that figure of 44,000 to 98,000 lives [lost each year as a result of errors] is emblazoned in their minds, history, and society.

It was probably the very first time we’d clearly swept away the curtains of silence that had defined the state of the healthcare at the time. A state that was somewhat complacent, and in many cases intentionally withholding the truth about healthcare. It was even the first time that many of us who worked in healthcare understood the magnitude of harm. It was such a sobering reality of what had been happening.

I think the other key thing about To Err is Human is that it was a real clarion call with its specific recommendations. Many recommendations that most of us in society would have already expected to be in place for our protection when we’re at our most vulnerable. [Moreover,] the industry that I think most of us expected, trusted, and believed was taking the best care of us possible, really showed some of its gaps and opportunities for improvement in a very powerful way.

Getting the report published at that time was really interesting. I’ve often thought about what if To Err is Human was published today, with the social media power that we have. Would it be any more or less impactful? Given we were in the more traditional world of reporting [when it came out] the impact, breadth, and reach was impressive for something of that nature. There wasn’t anyone who could look at that title and say, “This isn’t important in my life in some way.”

Q: In what areas has the patient safety field improved in the past 20 years? And what areas still need improvement?

McGaffigan: There’s been some nice improvement [that] I think has occurred because of To Err is Human; there was some governmental investment in initiatives to improve safety. We’ve seen, over the years since the publication, progress in some key areas. Mostly around some circumscribed projects, like efforts to reduce central-line infections or catheter-associated infections and falls. That’s been incredibly important, it’s probably saved more lives than we can realistically count, we have a difficult time measuring those harms and improvements to that extent.

Ironically, [that’s] emblematic of the problem we still have today, where we’re often tackling many of these problems with a piecemeal approach—often with great fervor and excitement. While we’re making progress in some of those areas, the approach is relatively reactionary and focused on fixing the circumscribed things. Particularly at the point of care, it has ignored the systemic issues that continue to allow fault lines in healthcare to prevail.

Some other areas of improvement are some great leaders who seem to have embraced the core values of safe and quality care as their business strategy. We’ve seen really bright spots of people and organizations who’ve identified the systemic issues that continue to get in the way of people’s really great intentions. But [some are] still working in systems that have not looked at and overhauled their system’s approach to safety. We continue to have some challenges.

Yet, there are some bright spots of systems that have unified their vision of safety for patients and their workforce in an effort to keep people free from harm. Because at the same time we’re talking about harms and safety of patients and families, the same challenges are pervasive in our workforce when you look at things like occupational injury rates.

So leaders have said, “I’m taking a unified approach to safety and everything we do in our organization matters, including to our most vital assets, our employees, those that provide care. [That] is how I’ll approach the problem.”

One of the things leaders have been able to do is say that they don’t rate safety as a higher or lower priority. [They say,] “It is my purpose, it’s my reason for being in this role in the first place, and not something that can be prioritized.” While leaders certainly need to make adjustments in how they invest in [safety] initiatives, these leaders have shown us that if you never accept anything less than zero harm for patients and workforce, then we will ultimately be successful in improving the health and vitality of our systems.

Q: What do you think the next big step in patient safety is going to be or needs to be?

McGaffigan: We talk about so many things when we talk about where we need to be to improve healthcare and quality of care. And lots of times, and we see this particularly in election years where have discussions and debates about healthcare, what we’re really not getting at is saying, “Regardless of the models we have for healthcare, care must first and foremost always be safe.”

That’s going to be the real differentiator for people who will ascend to office at some point in time, and who will be in the driver’s seat saying, “We’re not going to let conflicts and other things get in the way of doing what we expect to be done in healthcare.” That includes not just policymakers and elected officials, but leaders and all of us caring for patients saying we’re going to be authentic, transparent, and cohesive in addressing care.

There’s a piece of this centered around the reality that if our leaders are not impatient about where we stand with patient safety right now, then we’ve got a lot of work to do. There are a number of people who’ll say, “I am impatient, I’m going to use this impatience to be constructive and unified in advancing care. Particularly in putting the person back in the driver’s seat of their health and their healthcare.”

I think we have viewed patients as commodities instead of real champions of the care that is right and appropriate for them, [which is] an interesting irony of healthcare. Don Berwick, founder of IHI, has always said, “We are guests in our patients’ lives.” Patients are at the forefront and including them meaningfully in all aspects of improving care is absolutely vital.

When it comes to understanding how to anticipate and address harms, recent experiences [have shown] it’s been smart people at the point of care with patients and families who’ve have pointed out risks in the system. They’ve been correct in identifying those areas of risk and the unfortunate harm that has occurred as a result.