Fourth century BC | Hippocrates writes, “I will never do harm to anyone,” which is later translated (and changed) into “Primum non nocere,” or “first do no harm.” |
1857 | Ignaz Semmelweiss publishes his findings, demonstrating that hand disinfection leads to fewer infections (puerperal fever). |
1863 | Florence Nightingale, in Notes on Hospitals, writes, “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” |
1911 | Ernest Codman, a Boston surgeon, establishes his “End Result” hospital—with a goal of following and learning from patient outcomes, include errors in treatment. |
1917 | The first specialty board (ophthalmology) is formed. Ultimately, 24 boards are founded to certify physicians in the United States. |
1918 | The American College of Surgeons begins the first program of hospital inspection and certification. In 1951, the program becomes the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now the Joint Commission. |
1959 | Robert Moser, an Army physician, publishes Diseases of Medical Progress, arguing that iatrogenic disease is common and preventable. |
1964 | Elihu Schimmel, a Yale physician, publishes one of the first studies of iatrogenic illness, finding that 20% of patients admitted to a university hospital experienced an “untoward episode.” |
1977 | Ivan Illich publishes Limits of Medicine. Medical Nemesis: the Expropriation of Health, arguing that healthcare is actually a threat to health. |
1985 | The Anesthesia Patient Safety Foundation (APSF) is founded, a year after Jeffrey Cooper's seminal paper analyzing failures in anesthesia machines. Twelve years later, the National Patient Safety Foundation is founded, modeled on the APSF. |
1990 | James Reason publishes Human Error (and, seven years later, Managing the Risks of Organisational Accidents), describing his new theory of error as systems failure. His work will go undiscovered by healthcare until Leape's 1994 JAMA article. |
1991 | Publication of Harvard Medical Practice studies (from which the IOM later derives its 44,000 to 98,000 deaths/year estimate). |
1994 | Lucian Leape publishes Error in Medicine in JAMA, the first mainstream article in the healthcare literature arguing for a systems approach to safety. |
1999 | The release of the IOM report, To Err Is Human, creates a media sensation and begins the modern patient safety movement. |
2000 | Following the IOM report, the UK's National Health Service releases another major report, An Organisation with a Memory. |
2001 | The IOM releases its Quality Chasm report. |
2001 | The Agency for Healthcare Research and Quality (AHRQ) receives $50 million from Congress to begin an aggressive patient safety research and improvement program. |
2002 | The Joint Commission releases its first National Patient Safety Goals. |
2002 | The National Quality Forum launches its list of Serious Reportable Events (the “Never Events” list), which later becomes the scaffolding for public reporting and “no pay” programs. |
2003 | The Accreditation Council on Graduate Medical Education (ACGME) institutes duty-hour regulations, limiting residents to 80 hours/week. |
2004 | The U.S. government creates the Office of the National Coordinator ... |