Former President & CEO, INTEGRIS Health

To Err is Human

Published in The Journal Record
September 24, 2014

Sometimes it takes a catastrophe to alert us to flaws in our systems.  It took 9/11 to jolt us into recognizing the deficiencies in our intelligence gathering apparatus and the failure of agencies such as the FBI and military intelligence to work together.  A similar alert to a painful truth happened in 1999 when the Institute of Medicine published the document, “To Err is Human.”  The report noted that as many as 98,000 Americans died in hospitals annually because of mistakes, sloppy technique, or plain inattention to detail.  The IOM said the cost of this plethora of errors was almost $30 billion and was incalculable in terms of human loss.  What was worse the report alleged that hospitals had little incentive to improve because the payment system made them insensitive to their errors.  In other words since hospitals were paid on the basis of what we did our errors only led to more services for which we were paid.

After the hospital industry got over its initial shock it realized the report was, unfortunately, mostly true.  Jolted by these revelations the field rose to the occasion and began what has come to be known as the quality improvement era.  With few exceptions hospitals today have instituted redundant systems to insure that errors happen far less frequently.  Physicians, nurses, and technicians worked together in elaborate mechanisms to reduce errors.  Hospital web sites are now replete with data on the hospital’s track record in avoiding mistakes.  In a renewed spirit of transparency you find hospitals self-reporting success rates in reducing errors such as patient falls and nosocomial infections.

Hospitals have made the transformation from a work environment where the physician was solely responsible for catching mistakes to a team approach where elaborate systems and multiple sets of eyes examine every process, thus ensuring that serious mistakes get caught early and often.  Unfortunately, even with enhanced vigilance some errors manage to escape the web of safeguards and protections and patients wind up getting harmed, but the record of self-improvement is well documented.  The result, however, is that a public embarrassment stimulated the hospital field to significantly clean up its act.

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