A Call for Change
To Err Is Human declared that the health care industry needed to take the following steps to make health care safer:
- Create leadership roles, research patient safety issues and develop tools and protocols to enhance knowledge of safety issues that exist;
- Create nationwide mandatory and voluntary error reporting systems so that it could identify and learn from medical errors;
- Raise safety standards through the use of oversight organizations, professional groups and health care purchasers; and
- Implement safety systems that enhanced safe practice at the health care delivery level.
There was an initial flurry of activity following the IOM report in 1999. Five years after the study was released, the federal government, private foundations, health plans, hospitals and clinics were all investing more in patient safety then they had been in 1999. The End of the Beginning supra, at 543. Notwithstanding this fact, as early as 2004, there was recognition that efforts to advance patient safety were not moving forward comprehensively enough to be responsive to the problem ld. Studies of specific hospital systems revealed that while some areas of patient safety systems were improving, other were declining due to changing hospital priorities, budgets and philosophies. Daniel R. Longo, OblSb, ScD, The Long Road to Patient Safety: A Status Report on Patient Safety Systems 294 JAMA 2858, 2863 (2005). (hereafter ''The Long Road to Patient Safety'').
In To Err Is Human, the IOM called for a 50% reduction in medical errors in five years, but 10 years later it was clear that progress in the area of patient safety was still far short of that goal. Lucian Leape, et al., Transforming Healthcare, a Safety Imperative, 18 Qual. Saf. Health Care 424 (2009). Indeed, one commentator observed that "[s]hockingly modest progress has been made given the impact of the problem, how many people were made aware of it and how many efforts have been made to address it." 10 Years, 5 Voices 1 Challenge, supra, at 28. ''The current status of hospital safety systems is not close to meeting IOM recommendations." The Long Road to Patient Safety, supra, at 2858. Data from recent studies measuring safety progress suggests that "patient safety progress is slow, and cause for great concern." ld.
Why the Loss of Momentum?
Various reasons have been given for loss of momentum in the patient safety movement over the last 10 years. First, there was no organization set up to implement and oversee the plans set forth in To Err Is Human. 10 Years, 5 Voices 1 Challenge, supra, at 28. Additionally, the health care industry has displayed a reluctance to engage in recommended error reporting systems. ld. Although we are beginning to see changes, for the most part, payment systems throughout the last 10 years generally did not reward patient safety or penalize unsafe practices. ld. at 27. Finally, "Some of this lack of progress may be attributable to the persistence of a medical ethos, institutionalized in the hierarchal structure of academic medicine and health care organizations, that discourages teamwork and transparency and undermines the establishment of clear systems of accountability for safe care." Transforming Healthcare, a Safety Imperative, supra, at 424.
A Scathing Review
More of the Same?