Although Hippocrates said “first, do no harm” over 2000 years ago and many hospitals have long hosted conferences to discuss errors (Morbidity and Mortality, or “M&M,” conferences), until recently medical errors were considered an inevitable by-product of modern medicine or the unfortunate detritus of bad providers. This began to change in late 1999, with the Institute of Medicine's (IOM) publication of 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.
The IOM 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 or the wrong limb being operated on, chemotherapy overdoses, botched transplants, patients released from the emergency department (ED) only to die later from myocardial infarction or aortic dissection, and more (Table 1-1).
Table 1-1 Selected Medical Errors that Garnered Extensive Media Attention in the United States* ||Download (.pdf)
Table 1-1 Selected Medical Errors that Garnered Extensive Media Attention in the United States*
|An 18-year-old woman, Libby Zion, daughter of a prominent reporter, dies of a medical mistake, partly due to lax resident supervision||Cornell's New York Hospital||1984||Public discussion regarding resident training, supervision, and work hours. Led to New York law regarding supervision and work hours, ultimately culminating in ACGME duty hour regulations (Chapter 16)|
|Betsy Lehman, a Boston Globe healthcare reporter, dies of a chemotherapy overdose||Harvard's Dana-Farber Cancer Institute||1994||New focus on medication errors, role of ambiguity in prescriptions and possible role of computerized prescribing and decision support (Chapters 4 and 13)|
|Willie King, a 51-year-old diabetic, has the wrong leg amputated||University Community Hospital, Tampa, Florida||1995||New focus on wrong-site surgery, ultimately leading to Joint Commission's Universal Protocol, and later the surgical checklist, to prevent these errors (Chapter 5)|
|18-month-old Josie King dies of dehydration||Johns Hopkins Hospital||2001||Josie's parents form an alliance with Johns Hopkins' leadership (leading to the Josie King Foundation and catalyzing Hopkins' safety initiatives), demonstrating the power of ...|