Executive Summary
In 1999, the Institute of Medicine (IOM) shocked the nation with its estimate that 48,000 to 98,000 Americans die each year in the hospital—not from the illnesses or injuries for which they sought treatment, but because of mistakes and oversights in medical care. Although the numbers cited by the IOM were eye catching, the statistics were compelling because they captured a troubling idea: people can be harmed by care meant to help them.
The title of the IOM's report, To Err Is Human: Building a Safer Health Care System, emphasizes the fact that humans are prone to error. Therefore, the report contends, keeping patients safe from harm cannot depend on human perfection. Industries such as aviation and nuclear power achieve highly safe operations by taking human fallibility into account when people are trained, systems are designed, and organizations are managed.
The IOM report raised public and professional awareness of the need for change and galvanized positive action from many parts of the health care system. Before its publication, experts and leaders were working to educate others about the problem and to discover and demonstrate practical means for improvement. In more recent years, these efforts have intensified and more organizations and individuals have joined the cause. Nevertheless, experts agree that far more needs to be done to realize the vision of the IOM report.
This report, commissioned on the fifth anniversary of To Err Is Human, illustrates innovations in five areas that hold great promise for improving patient safety if applied nationally:
- promoting an organizational culture of safety,
- improving teamwork and communication to promote patient safety,
- enhancing rapid response to prevent heart attacks and other crises in the hospital,
- preventing health care-associated infections in the intensive care unit, and
- preventing adverse drug events throughout the hospital.
Using 10 case studies, this report describes the actions taken and lessons learned from organizations, teams, and collaborations, with suggestions for those seeking to replicate these successes. The organizations studied range from large integrated delivery systems to small community hospitals. Some have been recognized as leaders, while others are lesser-known innovators. Likewise, some of these efforts are now mature, while others are showing great promise. Overall, the cases demonstrate that improvement can occur in any organization where there is leadership, purposeful application of methods, and the will to change for the sake of patient safety.
One overriding lesson emerges: the programs identified organizational cultural change—the creation of a "patient safety culture"—as the critical element in making patients safer. Organizations seemed to differ chiefly in the methods used to instill a safety culture. The first two case studies examine organizations that have undertaken wide-ranging organizational change strategies, while the others describe more specific approaches. Regardless of method, the goal is a safety culture that promotes continuing innovation and improvement.
The organizations and teams studied for this paper have reported impressive improvements in patient safety and related organizational performance, including:
- substantial reductions in observed adverse events and certain hospital-acquired infections;
- apparent elimination of serious errors such as reported wrong-site surgeries;
- reduction in death rates;
- improvement in safety attitudes, teamwork, and communications behaviors associated with improved safety performance;
- increased reporting of safety incidents and more effective investigations into their causes, leading to more useful recommendations for changes to prevent recurrence;
- enhanced nursing morale and decreased nursing turnover and vacancies;
- more efficient use of staff time by eliminating repeated work and delays; and
- cost-savings resulting from shorter hospital stays.
Many of the cases demonstrate a correlation between patient safety and other domains of quality improvement. For example, collaborative rounds improved awareness of safety issues as well as patient- and family-centeredness of care and clinical outcomes. Interventions to improve safety through teamwork and communication improved staff morale and reduced nursing turnover. Empowering staff with improvement tools and knowledge is likely to have spillover effects on other domains of quality. The individuals, teams, and organizations studied were frequently engaged in other types of quality improvement activities or were considering ways to apply their learning to additional areas. These signs of collateral benefits and connections suggest that patient safety should not be approached as an isolated domain of quality.
The organizations profiled here would readily admit to being on only the first leg of the journey. Much more work is needed to achieve a truly safe environment for patients. These experiences, therefore, should be seen as a source of inspiration and encouragement to achieving even higher levels of performance. Although the cases focused on hospital settings, the lessons learned here are potentially applicable to ambulatory care environments, where patients receive most of their health care.
Table ES-1. Summary of Case Study Sites, Interventions, and Results | |||
| Organization | Setting | Intervention | Selected Results |
| Sentara Norfolk General Hospital, Norfolk, Va. | A 569-bed, level 1 trauma center; one of six hospitals operated by Sentara Healthcare, a regional integrated health care delivery network | Accelerate patient safety improvement through a multifaceted culture change program involving setting and monitoring behavioral expectations, enhancing analytic capabilities, and streamlining and focusing on critical policies |
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| U.S. Dept. of Veterans Affairs, National Center of Patient Safety, Ann Arbor, Mich. | An integrated health care system that serves 5.1 million veterans and 7.6 million enrollees at more that 1,300 sites nationwide | Lead organizational cultural change by empowering local facilities and frontline staff with proven tools, methods, and initiatives for patient safety improvement |
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| Kaiser Permanente, Orange County, Calif., and Northern California region | Local medical centers of an integrated group-model health maintenance organization with 8.2 million people enrolled nationally | Initiate a preoperative safety briefing and a perinatal patient safety project as part of a program of organizational learning to promote effective teamwork and communication in high-risk areas |
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| Concord Hospital, Concord, N.H. | A 295-bed community hospital that annually treats 250 patients in its cardiac surgery program | Use collaborative rounds involving all members of the care team with the patient and patient's family to proactively identity and prevent potential errors and safety threats |
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| Missouri Baptist Medical Center, St. Louis, Mo. | A 489-bed acute care hosptial within BJC HealthCare, a health system comprising 13 hospitals and other facilities | Establish a rapid response team to intervene early with patients showing signs of medical deterioration before the suffer acute crises |
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| Johns Hopkins Hospital, Baltimore, Md. | A 14-bed oncology surgical ICU and a 15-bed surgical ICU within a 900-bed academic medical center; one of three acute care hospitals in the Johns Hopkins Health System | Implement a comprehensive unit-based safety program that empowers staff to identify and eliminate patient safety hazards following eight action steps |
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| VHA, Inc., Transformation of the Intensive Care Unit National Collaborative | More than 40 ICUs in diverse community hospitals nationwide that are members of VHA, a health care cooperative serving not-for-profit health care organizations | Focus all members of the care team on adhering to a "bundle" of evidence-based care practices associated with improved patient outcomes |
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| Allegheny General Hospital, Pittsburgh, Pa. | A medical ICU and a cardiac care ICU in an 829-bed academic health center, part of six-hospital West Penn Allegheny Health System | Apply the Perfecting Patient Care approach, modeled on principles of the Toyota Production System, to specify best practices, eliminate variations from standards, and work toward ideal performance |
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| Institute for Healthcare Improvement, Cambridge, Mass. and Premier, Inc., San Diego, Calif. | A nonprofit organization that works with health care institutions worldwide to spread quality improvement, and an alliance of more than 200 not-for-profit hospitals and health systems | Develop a simple trigger tool that organizations can use to measure the incidence and kinds of adverse events, so as to prioritize areas for improvement, design appropriate interventions, and track the effect of changes over time |
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| OSF St. Joseph Medical Center, Bloomington, Ill. | A 165-bed acute care hospital, part of OSF HealthCare, a six-hospital integrated health care network based in Peoria, Ill. | Reduce adverse drug events by improving the process of medication reconciliation, the safe use of high-risk medications, and the reliability of medication dispensing |
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| Note: ICU = intensive care unit. | |||