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The 20th anniversary of “To Err is Human”: Improving patient safety

This year marks the 20th anniversary of the National Academy of Medicine (NAM)’s To Err is Human: Building a Safer Health System report. This landmark report recognized that medical errors and patient harm are a pervasive and unacceptable problem in healthcare. More importantly, it identified the creation of safety systems as a critical approach that can reduce errors.

Allscripts recognizes we must do our part, and we partner with a wide range of stakeholders to improve patient safety. Improvement is a continuous process that is being made, thoughtfully and steadily.

Identifying the problem: medical error

Preventable adverse events are a leading cause of death in the United States. When the report was released, an estimated 44,000 – 98,000 Americans were dying in hospitals each year because of medical errors.

Unfortunately, despite attention that To Err is Human brought to the issue, medical errors are still a significant problem. Recent reports indicate that the initial statistic was an underestimate, with more than 250,000 deaths annually due to medical errors. Medical errors are the third leading cause of death in the U.S., behind cardiovascular disease and cancer.

Understanding the human factors for patient centered care

To propose solutions for this problem, we must understand that humans are naturally fallible. We have many intellectual strengths, but also have well-known limitations. It’s difficult for us to attend carefully to several things at once, recall detailed information quickly and have a strong computational ability. The report acknowledges that we are fallible and must take steps to mitigate our limitations.

We must create safety systems to reduce errors and eliminate harm in healthcare organizations. A system is a set of interdependent elements interacting to achieve a common aim. The elements may be both human and non-human (e.g., equipment, technologies).

The systems approach: A more comprehensive way to improve patient safety

The systems approach takes the view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations).

Rather than focusing corrective efforts on punishment or remediation, the systems approach seeks to identify situations or factors likely to give rise to human error and change the underlying systems of care to reduce the occurrence of errors or minimize their impact on patients.

There is no single solution or group that can offer a complete fix to this problem. However, different groups can, and should, make significant contributions to the solution. Large, complex problems require thoughtful, multifaceted responses. Preventing medical errors means designing the healthcare system at all levels to make it safer. Building safety into processes of care is a more effective way to reduce errors than blaming individuals for past errors.

To Err is Human: Building a Safer Health System brought public attention to the issue of medical errors and ways to tackle patient safety concerns. To continue the conversation on this serious challenge, read our recent eMagazine on Patient Safety.

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