Who doesn't make mistakes: Creating a safer healthcare system

Author: (USA) Linda T. Kohn
Publisher:
Publish Date: 2005-01-01
Features: According to expert estimates, as many as 98,000 people die each year in the U.S. from medical errors in hospitals, a number higher than those who die in car accidents, breast cancer, and AIDS. However, public awareness of these three causes of death far exceeds that of medical errors. In fact, the number of deaths from medical errors each year is significantly greater than the number of occupational fatalities. Although errors are easily identified in hospitals, the problem is that they occur in every healthcare setting, including "same-day surgery centers," outpatient clinics, retail pharmacies, nursing homes, and home care facilities. The heavy financial burden, coupled with the tragedies caused to patients and their families, makes medical errors a widespread and urgent issue in healthcare. Faced with these alarming statistics, the Institute of Medicine has launched a program to examine the quality of healthcare in the U.S. and has recommended a set of stringent reform proposals. "To Err Is Human" is the first public publication of a series of U.S. healthcare initiatives. It breaks the silence surrounding medical errors and their consequences but does not directly target healthcare professionals who commit these mistakes. After all, errors are made by people. Instead, the book proposes a national agenda, using state and local research findings to design a safer healthcare system and reduce errors, thereby improving patient safety. The book reveals the shocking reality of medical errors and the asymmetry between the events themselves and the public's understanding of them. It explores how laws, regulations, and market forces constrain and influence healthcare quality, as well as how medical errors are handled. Using a detailed representative case as an example, the book examines the causes of these errors. Without a doubt, if legal liability or other interests might hinder the reporting of errors, the book asks, "How can we learn from our own mistakes?" Compared to market-based priorities and efforts to balance official initiatives, the Institute of Medicine has proposed broad recommendations to improve leadership, enhance data collection and analysis, and guide the refinement of patient care systems. The book repeatedly emphasizes that healthcare professionals are not inherently bad people; what we need to do is create a safer healthcare environment. The book provides a clear prescription for improving patient safety and explains how patients themselves can influence the quality of care they receive. This book will be extremely important for federal, state, and local healthcare policymakers and regulators, licensing officials for healthcare professionals, hospital administrators, medical educators and students, healthcare providers, health journalists, patient advocacy lawyers, and patients themselves. On the occasion of the 77th anniversary of the founding of the People's Liberation Army of China, Professor Wang Xiaobo and others translated the first research report of the U.S. healthcare series, "To Err Is Human," which provides reference materials for healthcare institutions in China to formulate policies, improve systems, reduce medical accidents and errors, and ensure the safety of injured and ill patients. It is worth celebrating. The book begins with the executive summary report of the U.S. Healthcare Quality Commission, systematically introducing the staggering number of deaths due to medical errors in some U.S. regions and the billions of dollars in economic losses. It also introduces a comprehensive approach to improving patient safety, healthcare errors as one of the main causes of death and injury, why errors occur, the establishment of management institutions and disciplinary systems for patient safety, and an error reporting system.