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ADVERSE EVENTS, PREVENTABLE ADVERSE EVENTS, AND ERRORS

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Although the four words well known to every physician—“first, do no harm”—date back to Hippocrates over 2000 years ago, and many hospitals continue the time-honored tradition of hosting Morbidity and Mortality, or “M&M,” conferences to discuss errors, medical errors have long been considered an inevitable by-product of modern medicine or the unfortunate detritus of bad providers. The dialogue around medical error only began to change in the past generation, most dramatically in late 1999, with the National Academy of Medicine's (NAM, formerly the Institute of Medicine, IOM) publication of the landmark report To Err Is Human: Building a Safer Health System.1 This report, which estimated that 44,000 to 98,000 Americans die each year from medical mistakes, generated tremendous public and media attention, and set the stage for unprecedented efforts to improve patient safety. Of course, these seminal works built on a rich tapestry of inquiry and leadership in the field of patient safety (Appendix III), familiar to a small group of devotees but generally unknown to mainstream providers, administrators, policymakers, and patients.

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The NAM death estimate, which was drawn from thousands of chart reviews in New York,2,3 Colorado, and Utah4 in the late 1980s and early 1990s, was followed by studies that showed huge numbers of medication errors, communication problems in intensive care units (ICUs), gaps in the discharge process, retained sponges in the operating room—in short, everywhere one looked there was evidence of major problems in patient safety. Moreover, accompanying this information in the professional literature were scores of dramatic reports in the lay media: errors involving the wrong patient going to a procedure, surgery on the wrong limb, chemotherapy overdoses, botched transplants, patients released from the emergency department (ED) only to die later from myocardial infarction or septic shock, and more (Table 1-1).

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Table 1-1

SELECTED MEDICAL ERRORS THAT GARNERED EXTENSIVE MEDIA ATTENTION IN THE UNITED STATES*

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