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Medical Error
Major Reports
To Err is Human: Building a Safer Health System (2000, full text)
Historic report from Institute of Medicine.
 "Reducing one of the nation's leading causes of death and injury - medical errors - will require rigorous changes throughout the health care system, including mandatory reporting requirements, says a new report from the Institute of Medicine (IOM) of the National Academies. The report lays out a comprehensive strategy for government, industry, consumers, and health providers to reduce medical errors, and it calls on Congress to create a national patient safety center to develop new tools and systems needed to address persistent problems.
"The human cost of medical errors is high. Based on the findings of one major study, medical errors kill some 44,000 people in U.S. hospitals each year. Another study puts the number much higher, at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS."
Comments on "To Err is Human"
System and responsibility: three readings of the IOM Report on medical error
"This paper is an inquiry into the nature of the "systems" approach to human error."
Stephen R. Latham, American Journal of Law & Medicine. Summer-Fall, 2001
Foreword: preventing medical accidents: is "systems analysis" the answer?
 "The toll of medical injury is truly appalling. While the oft-quoted figures of 44,000-98,000 deaths per year are horrendous in themselves, little attention has been given to the accompanying estimates that over a million people are injured by medical treatments annually in the U.S. Even this number, shocking as it is, is clearly an underestimate. Without exception, every study that has examined specific types of injuries (such as adverse drug events, injuries related to use of medications) with more sophisticated methods finds rates of injury that are much higher than those indicated by the rather crude record-review and population-based studies that are so widely quoted. And autopsy studies suggest that preventable deaths may also be many more than 98,000."
Lucian L. Leape, American Journal of Law & Medicine, Summer-Fall, 2001
Crossing the Quality Chasm: A New Health System for the 21st Century (2001, full text)
"America's health system is a tangled, highly fragmented web that often wastes resources by duplicating efforts, leaving unaccountable gaps in coverage, and failing to build on the strengths of all health professionals, says Crossing the Quality Chasm: A New Health System for the 21st Century, a new report by a committee of the Institute of Medicine. The report calls for immediate action to improve care -- in all aspects and for everyone -- over the next decade, and offers a comprehensive strategy to do so."
Envisioning the National Health Care Quality Report (2001, full text)
"Beginning in 2003, the Agency for Healthcare Research and Quality (AHRQ) will produce an annual report on the national trends in the quality of health care delivery in the United States. AHRQ commissioned the Institute of Medicine (IOM) to help develop a vision for this report that will allow national and state policy makers, providers, consumers, and the public at large to track trends in health care quality. Envisioning the National Health Care Quality Report offers a framework for health care quality, specific examples of the types of measures that should be included in the report, suggestions on the criteria for selecting measures, as well as advice on reaching the intended audiences."
Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact (2000, full text)
Report of the Quality Interagency Coordination Task Force (QuIC) to the President (full text)
"On December 7, President Clinton directed the Quality Interagency Coordination Task Force (QuIC) to evaluate the recommendations in To Err is Human and to respond with a strategy to identify prevalent threats to patient safety and reduce medical errors. This report responds to the President’s request and provides an action plan to implement Administration initiatives designed to help prevent mistakes in the Nation’s health care delivery system."
Download pdf version here. (323k)
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Additional information
Medical Error: 1988-2000
Medical Error: 2001-Present
Antibiotic overuse and microbial resistance
Psychiatrogenics
AiA Yahoo Group (hundreds of articles about medical error and practices.)
Harvard Risk Management Foundation
Medication errors
(FDA Center for Drug Evaluation and Research)
20 tips to help prevent medical errors
Agency for Healthcare Research and Quality
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