The Institute of Medicine (IOM) defined patient safety as “freedom from accidental injury due to medical care or medical errors.”1 Patient safety problems cause hundreds of
thousands of preventable deaths each year—a recent analysis estimated that up
to 440,000 Americans die annually from medical errors in U.S. hospitals.2 A
2010 study by the U.S. Department of Health and Human Services (HHS) Office of
Inspector General (OIG) estimated that over a quarter of hospitalized Medicare
beneficiaries experience an adverse event during their hospital stay;
subsequent studies in other care settings estimated that the adverse event
rates among Medicare patients in Skilled Nursing Facilities (SNFs) and
rehabilitation hospitals are 33 percent and 29 percent, respectively. 3, 4, 5 Adverse
events can take many forms, including healthcare-associated infections (HAIs),
medication errors, falls, pressure ulcers, and other potentially avoidable
occurrences. The costs of these events are high and are passed on in various
ways—higher insurance premiums, taxes, lost work time and wages, and lower
quality of life, to name a few. Proactively addressing patient safety will
protect patients from harm and lead to more affordable, effective, and
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1 Kohn LT, Corrigan J, Donaldson MS. To Err is Human:
Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2 James JT. A new,
evidence-based estimate of patient harms associated with hospital care. J
Patient Saf. 2013;9(3):122-128.
3 HHS, Office of Inspector General (OIG). Adverse Events in Hospitals: National
Incidence Among Medicare Beneficiaries. Washington, DC: HHS; 2010.
4 HHS, Office of Inspector General (OIG). Adverse Events in Skilled Nursing
Facilities: National Incidence Among Medicare Beneficiaries. Washington,
DC: HHS; 2014.
Office of Inspector General (OIG). Adverse Events in Rehabilitation
Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: