The Problem
Problems of patient safety are pervasive and well documented in countries around the world. The publication in 1999 of the Institute of Medicine report, To Err Is Human, was a jarring call to action. Among its findings:
- Between 44,000 and 98,000 deaths per year in US hospitals result from adverse events — more than car accidents, breast cancer, or AIDS.
- Costs of preventable adverse events are estimated at between $17 billion and $29 billion annually.
In 2000, the United Kingdom Department of Health report, An organization with a memory, estimated 850,000 adverse events per year in UK hospitals — 10 percent of hospital admissions. A 1995 Australian study estimated an adverse event rate in hospitalized patients in that country of 16.6 percent.
Better Models of Care Exist
Many innovative organizations have made important breakthroughs in the design and performance of safer systems in health care over the past several decades. For example, advances in both patient safety and efficiency have been reported as a result of the effective use of guidelines, protocols, and evidenced-based medicine; the use of computerized patient records; and the use of technology. However, many of these promising improvements remain unused, fragmented, isolated, and dispersed; their full potential has not yet been tapped. Furthermore, many more safety breakthroughs are achievable by adapting innovations from outside health care — innovations in human factors and reliability engineering, information management, performance tracking, scheduling, communications, and so-called "lean production" — to the medication delivery and management systems, as well as to the health care system as a whole.
Results
See examples of how hospitals achieved drastic reductions in adverse drug events.
