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

@article{Bates2018TwoDS,
  title={Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety.},
  author={D. Bates and Hardeep Singh},
  journal={Health affairs},
  year={2018},
  volume={37 11},
  pages={
          1736-1743
        }
}
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… 
A Roadmap to Advance Patient Safety in Ambulatory Care.
TLDR
Evidence suggests that medication errors, diagnostic errors, and communication and coordination breakdowns are the most common causes of preventable harm among outpatients, and a roadmap of milestones is needed to accelerate progress.
Looking to the Future
  • P. Lachman
  • Medicine
    Textbook of Patient Safety and Clinical Risk Management
  • 2020
TLDR
In this chapter, four key areas are covered: the concept of culture and language is the foundation for safety and a change in culture is the first step, which will include the development of psychological safety and well-being for people who deliver care, and co-production of safety with those who receive care.
Reclaiming the systems approach to paediatric safety
TLDR
The theories of patient safety and principles to tackle the challenge ahead are explored and the introduction of root cause analysis and failure mode effects analysis, which aimed to understand the complex systems involved in providing healthcare, are explained.
Prevention strategies to identify LASA errors: building and sustaining a culture of patient safety
TLDR
Building and sustaining a culture of patient safety should be considered as a global top-down strategy which involved all the elements in the system (regulatory bodies, manufacturers and suppliers).
Operational measurement of diagnostic safety: state of the science
TLDR
The state of the science is outlined and practical recommendations for organizations to start identifying and learning from diagnostic errors are provided to help them begin their journeys to measure and reduce preventable diagnostic harm.
Master’s Programs in Patient Safety and Health Care Quality Worldwide
TLDR
This study reviews all the existing master’s-level degree programs worldwide and assesses them to determine trends and disagreements, highlighting the need for the development of program standards to ensure the quality of such programs, as have been developed in other professional fields.
Patient Safety: We've Come a Long Way.
TLDR
Patient safety has come a long way since the release of the 1999 Institute of Medicine report To Err Is Human, which revealed the immense size of the problem of preventable adverse events and took the lid off quality.
Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan
TLDR
The authors propose a 5-point action plan and corresponding policy levers to support development of LEDE organizations that stimulate scientific, practice, and policy progress needed for achieving diagnostic excellence and reducing preventable patient harm.
Fighting a common enemy: a catalyst to close intractable safety gaps
TLDR
Several changes have occurred in at least three safety-related domains: adoption of key attributes of safety culture (transparency, communication and collaboration); rapid implementation of safety practices to care for the previously often neglected healthcare workforce; and use of state-of-the-art health information technology to improve the safety of patients and clinicians within the healthcare delivery system.
Resilience in a prehospital setting - a new focus for future research?
  • E. Jeppesen, S. Wiig
  • Medicine, Business
    Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
  • 2020
TLDR
A better understanding is given of how the concept and inclusion of resilience can inspire a new approach for future research in prehospital settings to build and support resilient systems and processes in a prehospital setting.
...
...

References

SHOWING 1-10 OF 53 REFERENCES
Fifteen years after To Err is Human: a success story to learn from
TLDR
The historical profile of CLABSI is provided, comparing infection rates before and 15 years after the IOM report and offering new insights into what led to the substantial reductions in infections are offered.
The “To Err is Human” report and the patient safety literature
TLDR
The “To Err is Human” report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.
A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care
  • J. James
  • Medicine, Political Science
    Journal of patient safety
  • 2013
TLDR
The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed and fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary.
Application of electronic health records to the Joint Commission's 2011 National Patient Safety Goals.
TLDR
An overview of NPSG priorities for hospital quality improvement initiatives are patient identification, staff communication, medication labeling, infection control practices, medication reconciliation and interactions, and mitigation of suicide risks, and electronic health records, along with CPOE, CDS, and bar code medication administration, if designed, developed, implemented, and used correctly, potentially play critical roles in addressing these safety goals.
The incidence of diagnostic error in medicine
TLDR
It is argued that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error, and to initiate quality improvement projects aimed at reducing the risk of error and harm.
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
TLDR
Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
Estimating deaths due to medical error: the ongoing controversy and why it matters
TLDR
It is proposed that the new estimate that medical error was to blame for 44 000–98 Thousands deaths each year in the US hospitals is very likely to be wrong and risks undermining rather than strengthening the cause of patient safety.
Effect of nonpayment for preventable infections in U.S. hospitals.
TLDR
It is found no evidence that the 2008 CMS policy to reduce payments for central catheter-associated bloodstream infections and cathet-associated urinary tract infections had any measurable effect on infection rates in U.S. hospitals.
Funding Innovation in a Learning Health Care System.
TLDR
Although the federal government is a major investor in health-related research and could accelerate the development of learning health systems, the current efforts toward that goal may need a redesign of their own.
Re-examining high reliability: actively organising for safety
TLDR
Evidence suggests that healthcare is starting to organise for higher reliability, and standardised protocols and checklists, although imperfect, may hold promise for enhancing safer care.
...
...