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Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety

PIPSQC is pleased to share the recent special issue of Health Affairs, entitled "Patient Safety." This issue contains a comprehensive look at the latest research on the topic of patient safety. Almost 20 years after the publication of the Institute of Medicine's landmark study, "To Err Is Human," Health Affairs authors examine what progress has been made in the intervening years.

Related to the special issue, a Health Affairs event entitled "Patient Safety" was held on November 6th, wherein panels of journal authors presented topics including:
- Where Is the Patient In Patient Safety?
- The Role of Systems in Patient Safety
- Interventions to Improve Safety

The special issue is available at:
https://www.healthaffairs.org/toc/hlthaff/37/11

A video recording of the event is available at:
https://www.healthaffairs.org/do/10.1377/he20181024.13806/full/

A related editorial is available at:
Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety

ABSTRACT:

The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. Progress in addressing other hospital-acquired adverse events has been variable. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. In sum, the frequency of preventable harm remains high, and new scientific and policy approaches to address both prior and emerging risk areas are imperative. With the increasing availability of electronic data, investments must now be made in developing and testing methods to routinely and continuously measure the frequency and types of patient harm and even predict risk of harm for specific patients. This progress could lead us from a Bronze Age of rudimentary tool development to a Golden Era of vast improvement in patient safety.