• 1999: To Err Is Human (IOM Report)
  • 2001: Crossing the Quality Chasm (IOM Report)
  • 2002: Quality Forum introduces the concept of “never events” — a list of serious preventable adverse events
  • 2003: ACGME limited residents in the US to 80-hour work week
  • 2004: Joint Commission published national safety goals
  • 2004: IHI launched its 100,000 lives campaign
  • 2007: ICU checklist published that improved safety in ICUs
  • 2007: NPSF developed the Lucian Leape Institute and started publishing white papers
  • 2010: HITECH act passed incentivizing the use of electronic health records’
  • 2015: HHS changes Medicare payment policy to be based on value rather than volume. 

Most lessons about Patient Safety begin with the Institute of medicine’s 1999 report “To Err Is Human” which estimated that we kill 44k to 98k people each year due to medical errors and adverse events – the equivalent of two jumbo jets crashing into each other every day for a year. This report implies that healthcare providers are the third leading cause of death in the US. 

There have been articles doubting the accuracy of this report. Whether true or not, this report ignited the patient safety movement as we know it. And it is still our responsibility to identify and minimize “errors” in medicine while increasing the quality of care we deliver. Remember we took an oath to do no harm. 

The Six Aims

In 2001, the IOM released “Crossing the Quality Chasm” in which they identified six aims for improvement of the quality of care (which can be made to spell STEEEP). Providers are asked if the care they offer is:

  1. safe,
  2. timely,
  3. efficient,
  4. effective,
  5. equitable, and
  6. patient-centered.

Never Events, Safety Goals & Value

In 2002, the quality forum introduced the concept of “never events.” This is an exhaustive list of serious preventable adverse events including things like surgery on the wrong site or wrong patient, the use of contaminated drugs or devices, discharging a patient who is unable to make decisions, wrong drug, wrong dose or used on the wrong patient. You can find the entire list on the qualityforum.org website.

In 2004, the joint commission published national safety goals. These are updated periodically and are also available on their website. It includes things such as identifying patients correctly, using medications safely, preventing mistakes in surgery and preventing infections. 

The patient safety movement has continued to grow and now also incorporates the concept of value. Previously, patients (and insurers including the government) were charged whenever a procedure was done, regardless of the quality. A patient can be charged for a hip replacement that had a bad outcome, the subsequent hospital care to deal with the adverse event, and then the second hip replacement to fix the first one. By incentivizing value instead of procedures, we hopefully motivate the system to prevent adverse events in the first place. The cost for complications would now be borne by the hospital, not the patient. The concept of value includes several components including safety, quality, and the patient experience, divided by the cost. 

value =(safety+ patient experience + quality) / cost