The year was 1999 — now 20 years ago — when a landmark report from the Institute of Medicine (IoM) revealed that as many as 98,000 patients die in the U.S. each year from preventable medical errors.
Since then, little has been done to improve patient safety. In fact, most experts believe that the original report’s figure of 98,000 patients greatly underestimated the true extent of the problem.
The report, called “To Err is Human: Building a Safer Health System,” caused an uproar when it was published in 1999. The yearly death statistic alone sparked news stories, congressional hearings, and a widespread sense of anxiety in the healthcare community. It revealed how medical errors stem not just from individual failures by doctors, but from large systems and conditions that fail to preempt and, in some case, encourage mistakes.
Medical Errors: ‘To Err Is Human’
At the heart of the matter is a snowball effect, where seemingly small oversights balloon into life-threatening errors. One example is how drugs with similar-sounding names and packages are often stored in proximity to one another, leading to faulty or mistaken prescriptions.
Some errors are institutional, such as poor equipment training or a work culture that discourages health professionals from speaking out. Because the source of an error is not always traced to a single event or individual, the extent of a problem can often be difficult to quantify. That’s why the 1999 report was so earth-shattering: No one saw it coming.
After the study was published, patients, professionals, and regulators all seemed to agree that the number of deaths caused by medical error was unacceptably high. To tackle the issue, insurance providers, hospitals, medical organizations, and government agencies outlined goals for improving transparency and accountability.
The IoM report issued its own recommendations, promoting the goal of reducing medical errors by 50% within 5 years. While the IoM has not followed up on that goal, today’s healthcare industry shows few signs of progress.
In 2016, a study by Johns Hopkins University estimated that more than 250,000 people are killed each year by medical mistakes — well over twice the 1999 estimate. Adding to that grim statistic is a recent analysis by the World Health Organization (WHO), which found diagnostic or medication errors harm one out of every 10 hospital patients worldwide.
Such findings suggest patient safety in the years since the IoM report has actually worsened.
Medical Mistakes: Who Is to Blame?
In the wake of the 1999 report, concrete efforts were taken to reduce medical errors, but according to Kathleen Sutcliffe, a professor of Medicine and Business at Johns Hopkins University, they lacked ambition.
Writing in Time magazine, Sutcliffe explained how most decisions were left to managers and administrators — the very people whose main concerns always center around profitability. Few if any measures were taken to remedy the social or psychological causes of medical errors.
As a result, hospitals and medical institutions merely issued checklists, installed some hand-sanitizing stations, and promoted workplace safety measures with no oversight or follow-up. The government, meanwhile, did little to intervene or impose new patient safety standards.
In 2009, the Safe Patient Project of Consumers Union, not satisfied with the state of patient safety, issued a progress report on the recommendations put forth by the original 1999 study.
The report noted the following:
- Few hospitals had adopted the IoM’s recommended systems for preventing medication prescription errors.
- No national system of accountability through transparency had been put in place.
- No national agency had been established to encourage and track improvements in patient safety.
- Doctors and health professionals had not been held to any higher standards of competency.
Summarizing its findings, that report also stated:
“Efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress.”
20 Years Later: Has Anything Improved?
Two decades after “To Err Is Human,” it seems little progress has been made. Much of the debate still seems to be around how to define a “medical error.” Few can argue, however, that the problem is anything but grave. That IoM statistic of 98,000-deaths-a-year is seen by most experts as a baseline figure.
For patient advocates, the true number is less important than the cultural and institutional problems it exposes—such as the fact that medical errors are difficult to quantify because professionals often are not even aware when they have made a mistake.
Changing culture is a tough task for any industry. For the healthcare sector, change has to involve everyone from nurses to CEOs. The challenge is in figuring out how responsibility is divvied up between those extremes. It is all too common for those at the top to blame those at the bottom.
But even accountability is just one piece of the pie. Dr. John T. James, an author and former chief toxicologist at NASA, has dedicated most of his life to researching and improving patient safety. In a 2013 study for the Journal of Patient Safety, James outlined the need for a national patient bill of rights:
“All evidence points to the need for much more patient involvement in identifying harmful events and participating in rigorous follow-up investigations to identify root causes.”
Empowering patients with the proper knowledge to make healthcare decisions is critical to any attempts at reducing medical error. On his website, James also suggests the need for medical organizations to implement patient safety policies, as well as laws that favor safer care, transparency, and accountability.
James’s recommendations mirror those put forth by other experts, like John Hopkins’ Kathleen Sutcliffe, who says hospital administrators and industry executives need to realize that healthcare, including patient safety, is far too complex to exist in a vacuum:
“We live in an era of multifaceted problems that call for multidisciplinary approaches,” Sutcliffe writes. He continued:
“Advances in anesthesia safety, for example, would not have come without the input of engineers. Experts with perspectives from outside of medicine should be welcomed to any serious discussion of how to improve patient safety, and their insights heeded.”
Patients, as well as doctors, insurers, and administrators, have to face up to their own role in patient care and safety. Such a perspective offers a big web of accountability that — if anything — seems more difficult to navigate. But we cannot lose sight of individual responsibility either.
Doctors or medical professionals who make serious medical mistakes cannot be left off the hook. If individuals are not allowed to face the consequences for serious medical errors, how can they be expected to avoid those mistakes in the future?
It could not be clearer that the culture around medical errors needs to change. So long as negligence remains free from consequence, it will be permitted to exist.
That, most seem to agree, is a rule as old as time.