Five Years After To Err Is Human

TLDR

The Institute of Medicine called for a national effort to make health care safe, and although progress has been slow, the pace of change is expected to accelerate with electronic health records, safe practice diffusion, team training, and patient disclosure. The authors argue that a national commitment to strict, ambitious, quantitative safety goals and pay‑for‑performance incentives for high‑safety hospitals is needed to achieve the IOM’s vision. They propose that pay‑for‑performance incentives directed at high‑safety hospitals, coupled with stakeholder agreement on explicit safety goals by 2010, would drive improvement. The IOM report has shifted the conversation toward system change, engaged stakeholders, and prompted hospitals to adopt safer practices, though progress remains slow.

Abstract

Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010.