10 Years After To Err is Human Report Reveals Massive Safety Problems Are We Better Off? What Must Be Done to Ensure Safety? 

Washington DC (May 29, 2009) –As we approach the 10 year anniversary of the Institute of Medicine’s (IOM) ground-breaking report on safety - "To Err is Human" - it is a good opportunity to reflect on progress made and the distance left to cover. Progress in some areas has been significant, but we can and must do much more to ensure that every patient is receiving safe, effective care every time they see their healthcare providers.

A disturbing report released recently by the Agency for Healthcare Research and Quality (AHRQ), found measurable improvement in fewer than half of the 38 patient safety measures examined, like accidental lacerations and catheter-associated infections. The report found that one of every seven hospitalized adults on Medicare had experienced at least one adverse event. Research shows it takes 17 years before evidence-based practices are incorporated into widespread clinical use.

"While improvements have been made in patient safety, they must spread farther and faster," said Janet Corrigan, National Quality Forum (NQF) president and CEO. "We cannot afford- in lives or dollars- to provide care that is unsafe. Every patient deserves safe, high-quality healthcare, every time they receive care."

Corrigan says some of the recommendations in "To Err is Human" haven't been followed. "Our systems for reporting and learning from errors are a patchwork. This is an area where we have fallen short. " Corrigan also says we haven’t invested enough in redesigning our fragmented healthcare system or in engaging the public in preventing errors. "The entire healthcare team, including patients and family caregivers, need to be involved in improving quality and safety."

"Right now, in terms of patient safety, the glass is half full, but half full isn’t good enough."

To overcome barriers to a faster, more effective spread, NQF is ramping up its safety efforts with a year-long webinar series reaching practitioners at all levels in every corner of the nation, an updated safe practices report, and new measures related to the safety of lab testing.

NQF Safety Efforts

• Updated Safe Practices for Better Healthcare: These evidence-based Practices are ready-to-use tools to improve safety and have been evaluated, assessed and endorsed to guide large and small healthcare systems in providing the safest care possible. List of Safe Practices
• Safe Practices Webinar Series: The year-long series of webinars will address specific practices to guide the healthcare industry in more rapid adoption of safety measures. This month’s webinar addressed Healthcare Associated Infections. AHRQ found an average decline of nearly 1 percent in its patient safety measurements over each of the last six years. Contributing to the drop were increases in the rate of accidental punctures and lacerations during procedures and avoidable infections. The secretary of health and human services, Kathleen Sebelius announced $50 million in federal stimulus grants to help states combat infections associated with healthcare. She also challenged hospitals to reduce blood stream infections from central catheters by 75 percent over the next three years.
• Practices to Improve Laboratory Safety: Pre-testing error rates in laboratory medicine are as high as 75% and post-testing error rates are as high as 31%. Errors during these phases – such as improper patient identification – can lead to misdiagnosis or wrong treatment. Implementing safe practices can improve the safety of laboratory medicine. List of Laboratory Practices
  
  To spur deliver system reform, NQF convened the National Priorities Partnership, a diverse group working to transform healthcare from the inside out by setting national priorities and goals. Each of the partners is committed to taking collective action to improve the safety and quality of the healthcare system.

The IOM report "To Err is Human" noted the difficulty in achieving rigorous, consistently applied safe practices and transparency in a notoriously fragmented healthcare system. Through its work, NQF strives to focus attention on high-leverage areas, and to provide important "tools" that can be used to measure, report and improve.

The mission of the National Quality Forum is to improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs. NQF, a non-profit organization (qualityforum.org) with diverse stakeholders across the public and private health sectors, was established in 1999 and is based in Washington, DC.