Patient Safety At Ten: Unmistakable Progress, Troubling Gaps

TLDR

The 2009 IOM report “To Err Is Human” sparked a decade of patient‑safety initiatives driven by stricter accreditation, reporting demands, and growing IT adoption, yet progress remains limited by inadequate funding and poor measurement. Safety efforts received a B‑ grade, reflecting only modest improvement since 2004.

Abstract

December 1, 2009, marks the tenth anniversary of the Institute of Medicine report on medical errors, To Err Is Human, which arguably launched the modern patient-safety movement. Over the past decade, a variety of pressures (such as more robust accreditation standards and increasing error-reporting requirements) have created a stronger business case for hospitals to focus on patient safety. Relatively few health care systems have fully implemented information technology, and we are finally grappling with balancing "no blame" and accountability. The research pipeline is maturing, but funding remains inadequate. Our limited ability to measure progress in safety is a substantial impediment. Overall, I give our safety efforts a grade of B-, a modest improvement since 2004.