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QUALITY: Five years on from To Err Is Human

Nov 29, 1999 saw the release of possibly the most famous report in health care since the Flexner report excoriated the medical school system in the early 1900s. The report was called To Err is Human and it was created by an expert panel working under the auspices of the non-partisan Institute of Medicine. Based largely on the work done some 10 years earlier by the Harvard group looking at malpractice, To Err is Human made the leap into the public consciousness despite being an obscure report about the medical system, rather than a sexy report about new medical discoveries. Here is the IOM’s original press release.

At least two major news events in previous years had helped in the build-up–the death by wrong chemotherapy dose of the Boston Globe’s health columnist, Betsy Lehman, in the most prestigious cancer center in the most medically prestigious city in America, and the amputation of the wrong limb from a patient in a hospital in Florida. While this type of thing had been going on forever, patient safety suddenly became a screaming big deal, and it remains so today. However, it remains a big deal in the sense that medical errors are still routinely going on — in fact THCB reported just a few months back of an identical death by wrong dose of chemotherapy to that which killed Betsy Lehman. And just last week a Seattle medical center publicly apologized for a mix-up in which a patient died as a result of being injected with a toxin rather than a harmless dye.

The patient safety movement is also hamstrung by an unwillingness of both Congress and medical leaders to get really serious about the problem. Earlier this month in a survey by Bob Blendon at Harvard, in conjunction with Carolyn Clancy at AHRQ and the Kaiser Family Foundation, the public showed that they do not trust the medical system’s safety. Here’s the survey and the three authors also acknowledged the fact in the NEJM.

Throughout this entire time, or at least since the publication of his wonderful book Demanding Medical Excellence, Michael Millenson has been the leading lay critic of the medical establishment on its poor response to the patient safety issue, even following the IOM report. I asked Michael for his reaction on the five year anniversary. Here are his thoughts:

It’s official: the sage leaders of the health care industry have gathered for the five-year anniversary of the IOM To Err is Human report and concluded that not enough has been done to actually reduce the patient death toll since the report appeared.

It is, unfortunately, not a surprise that the equivalent of three jumbo jets crashing every two days continues to occur — although, in fairness, enough progress has been made that we may assume that the load factor on those jets has dropped somewhat. The death toll taken by tired residents gained national attention with the death of Libby Zion in the mid-1980s. Two decades later, strong rules limiting resident work hours have finally taken effect nationally. Wrong site surgery was the subject of sustained national headlines in 1995. JCAHO rules mandating the tremendously complicated solution — use a pen to mark the site — went into effect in 2004.

The fact is that 747s are not crashing in hospital parking lots; the preventable death toll remains largely invisible. Hard working, well-meaning physicians and nurses are all trying hard to do their best for patients, and their failures generally occur among people who were very sick to begin with. As the horror stories fade, Congress can barely summon the energy to mandate voluntary error reporting.

In two years we’ll have the five-year anniversary of the IOM’s Crossing the Quality Chasm. One can safely, as it were, predict that we will then be talking about the sad lack of progress in making evidence-based medicine an integral part of routine care.

One other thought. Health policy wonks had known about this for years. Why was this report become such a big deal in the first place? Millenson explains:

The IOM was lucky. The release came in a slow news time (post-Thanksgiving), when there was nothing new on various Clinton scandals and Boris Yeltsin, as I recall, was on the death watch but hadn’t died of alcohol poisoning or whatever. So: slow news day, catchy topic with soundbites, and real human interest examples (courtesy of newspaper stories) that allowed the TV folks to put real people on film — and you’ve got a big deal story. As opposed to the generalizations of most "reports," including Chasm.

Now, not pure luck. They were trying to make a splash. But timing was lucky. And they weren’t smart enough to realize the true elements in their success, ’cause they thought Chasm would be even bigger play because the topic was bigger. Sure, and putting out a report on problems with America’s plumbing systems will be a sure-fire media success, too.

Of course most people don’t know where the quote in the title of the IOM report comes from, but then again most people weren’t tortured through English literature class at their English boarding school the way I was. And the full phrase that Alexander Pope wrote?

Good nature and good sense must ever join;
To err is human, to forgive divine.

I think it’s fair to say that although we do have the "good sense" needed to make medicine safer, we don’t have the "good nature" required to put that sense into operation. So we don’t yet deserve any divine forgiveness.

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Gary Lampman

Great Article but what has been missing on this human Drama is the lack of Transparency and Accountability. Like a Cat covering up crap. Medical Professionals have the unprecedented ability to bury mistakes and settle claims with GAG orders. The Reported Claims are only those which are so egregious that it can not be Ignored. There will be mistakes from time to time. The problem is we give Grants as incentives to do the right thing and it becomes absorbed for other purposes. Instead of given incentives before these goals are met,those incentives need to be based on Achievements and… Read more »