The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety.
The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety.
The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety. Since its publication the recommendations in To Err Is Human have guided significant changes in nursing practice in the
United States.
In this Discussion you will review these recommendations and consider the role of health information technology in helping address concerns presented in the report.
To prepare:
Review the summary of To Err Is Human presented in the Plawecki and Amrhein article found in this weeks Learning Resources.
Consider the following statement:
The most significant barrier to improving patient safety identified in To Err Is Humanis a lack of awareness of the extent to which errors occur daily in all
health care settings and organizations (Wakefield 2008).
Review The Quality Chasm Series: Implications for Nursing focusing on Table 3: Simple Rules for the 21st Century Health Care System. Consider your current
organization or one with which you are familiar. Reflect on one of the rules where the current rule is still in operation in the organization and consider another
instance in which the organization has effectively transitioned to the new rule.
Post on or before Day 3 your thoughts on how the development of information technology has helped address the concerns about patient safety raised in the To Err Is
Human report. Summarize in one page how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.
References (mandatory)
PLAWECKI L; AMRHEIN D. Clearing the err. Journal of Gerontological Nursing. 35 11 26-29 Nov. 2009. ISSN: 0098-9134.
Wakefield M. K. (2008). The Quality Chasm series: Implications for nursing. In R. G. Hughes (Ed.) Patient safety and quality: An evidence-based handbook for nurses
(Vol. 1 pp. 4766). Rockville MD: U. S. Department of Health and Human Services.
Legal Issues
Ive made a mistake. This
simple statement or its mere
thought is enough to strike fear
within the most experienced and
knowledgeable of health care professionals.
No matter how many
times a procedure has been done or
a medication administered there is
always the likelihood of preventable
error. Each year the public
is reminded of the potential for
mistakes as the media report medical
horror stories where for example
unknowing patients have surgery
performed on the wrong body part
a wrong medication administered
or a foreign object errantly left
inside their bodies. These reports
highlight the biggest fear of health
care workerstheir own fallibility.
Through carelessness assumption
overt act or omission the health
care professional can easily err
and cause harm to the patient. In
addition to the pain caused to the
patient health care providers also
understand the devastating impact
that such errors can wreak on their
own personal and professional lives.
The purpose of this article is to
About the Authors
Mr. Plawecki is Registered Nurse
Rehabilitation Hospital of Indiana Indianapolis
and Dr. Amrhein is Resident
Physician Family Practice Medicine Ball
Memorial Hospital Muncie Indiana.
The authors disclose that they have no
significant financial interests in any product
or class of products discussed directly
or indirectly in this activity including
research support.
Address correspondence to Lawrence
H. Plawecki RN JD LLM Registered
Nurse Rehabilitation Hospital of
Indiana 4141 Shore Drive Indianapolis
IN 46254; e-mail: Lawrence.plawecki@
gmail.com.
doi:10.3928/00989134-20091016-01
Clearing the Err
Reporting Serious Adverse Events and Never Events in Todays Health Care System
Lawrence H. Plawecki RN JD LLM; and David W. Amrhein MD
Abstract
Absent an infinitesimal percentage most Americans seek health care services
due to a legitimate health issue. Fundamental within this relationship
is the understanding that health care professionals will do everything within
their power and expertise to alleviate the suffering of each patient they
treat. Unfortunately preventable medical errors do occur and the innocent
patient is left to suffer. In 1999 the Institute of Medicine
released To Err Is Human: Building A Safer Health System the
first mainstream publication calling for a change in the
culture of health care and the eradication of preventable
medical errors. In the 10 years since its publication
federal and state governments and agencies
have been proactive in attempting to meet the
recommendations originally proposed in To Err Is
Human. This article will review what has been accomplished
in this time frame.
iStockphoto.com/ Ireneusz Skorupa
26 JOGNonline.com
discuss the trend in todays health
care systems toward the reporting
of serious adverse events or never
events as well as the impactboth
impending and currenton the role
of geriatric nurses.
Refocusing and
Rebuil ding a Sa fe Heal th
Ca re System
In November 1999 the Institute
of Medicine (IOM) released a
profound call to action for everyone
involved in the health care community.
This statement entitled To Err
Is Human: Building A Safer Health
System began with a grim statistic
estimating that between 44000 and
98000 people died per year from
preventable medical errors as hospital
patients. The IOM (1999) report
defined medical error as the use of a
wrong plan of action to achieve an
aim or the planned actions failure
to be completed as intended. In
economic terms these errors were
estimated to cost between $17 billion
and $29 billion per year across the
country (IOM 1999). These financial
estimates include the costs of lost
income lost household productivity
and the cost of the additional health
care necessitated by the errors (IOM
1999). The more specific recommendations
posited by the IOM (1999)
for the prevention of medical errors
are discussed below.
The IOM (1999) report recommended
a four-tiered approach to
achieve a better safety record:
l Establishing a national focus
to create leadership research
tools and protocols to enhance the
knowledge base about safety.
l Identifying and learning from
errors by developing a nationwide
public mandatory reporting system
and by encouraging health care
organizations and practitioners to
develop and participate in voluntary
reporting systems.
l Raising performance standards
and expectations for improvements in
safety through the actions of oversight
organizations professional groups
and purchasers of health care.
l Implementing safety systems
in health care organizations to ensure
safe practices at the delivery level.
As a result of these broad recommendations
state and federal
governments agencies and health
care institutions were given notice
about the increased focus on the
prevention of medical errors and
consequently the improved safety
of the patient receiving treatment.
During the 5 years following the
IOM (1999) report progress began
to be made.
In 2001 the U.S. Congress appropriated
an annual budget of $50
million for patient safety research
(Leape & Berwick 2005). From
this appropriation the Agency for
Healthcare Research and Quality
(AHRQ) was codified as the federal
agency to oversee patient safety and
its improvement (Leape & Berwick
2005). AHRQ became an important
player in the new patient safety
movement by evaluating health care
practices to determine effectiveness
educating health care institutions
about how to best report errors and
adverse events and creating a roadmap
of evidence-based best practices
(Leape & Berwick 2005).
Using the roadmap created
by AHRQ the National Quality
Forum (NQF) (2007) created a
list of 27 serious reportable events
also referred to as never events
which were offered as the basis
for a potential national reporting
system chronicling patient safety.
The serious reportable events may
be divided into six separate categories
including surgical events
product or device events patient
protection events care management
events environmental events and
criminal events (NQF 2007). For
the purposes of this article however
the individual events will not be discussed
as the focus is to remain on
the implementation and evolution of
patient safety standards.
In 2005 the American Medical
Association (AMA) released
a report by Leape and Berwick
detailing the effects of the original
IOM publication. The AMA
report while admitting there had
been little measurable effect after
the release of the IOM report and
that no comprehensive nationwide
system for monitoring had been
put into existence discussed how
the focus of patient care had shifted
from fixing blame to implementing a
culture of safety (Leape & Berwick
2005). This alone can be considered
an impressive feat in todays increasingly
litigious society. Furthermore
Leape and Berwick (2005) identified
the four areas the health care system
needed to advance in the following 5
years to facilitate the transition to a
patient safety focus.
First Leape and Berwick (2005)
recommended the implementation
of electronic medical records. It is
argued that this implementation although
a substantial initial cost will
save the facility and pay for itself
due to the decrease in charges of adverse
events and increase in efficien-
Journal of Gerontological Nursing Vol. 35 No. 11 2009 27
cy of staff. Second as more methods
are implemented newer and safer
practices will be proven. The final
two advancements named in the
IOM (1999) recommendations can
be met as newly learned information
is disseminated through the health
care system and ultimately training
of health care workers continues
to evolve and improve. Last health
care professionals should then be
able to admit mistakes apologize
and improve communication with
patients as it has been found that
full disclosure of a mistake does not
increase the risk of a lawsuit being
filed (Leape & Berwick 2005).
Where are we now?
As the tenth year following To Err
is Human (IOM 1999) is drawing
to a close health care professionals
can readily see and appreciate
the changes being made to improve
patient safety and their own practice.
An inexhaustive list comparing several
states their attempts to improve
patient safety and new federal guidelines
are discussed below.
Minnesota
In 2003 Minnesota became the
first state to adopt a never events
law (Minnesota Department of
Health 2008). Initially this law
required Minnesotas hospitals
regional treatment centers and freestanding
outpatient surgical centers
to report these never events to the
Minnesota Department of Health
(2009). These events were then
reported to the public by the Minnesota
Department of Health (2008)
on an annual basis. In 2005 however
an amended law took effect
requiring Minnesota hospitals to report
the occurrence of a never event
publicly to the Minnesota Hospital
Associations web-based Patient
Safety Registry (Dotseth 2004).
In addition Minnesota Statutes
144.7065 (2005) requires applicable
facilities to investigate each reported
event report the underlying cause
of each event and take corrective
action to prevent the recurrence of
such an event. Lastly an annual report
required by Minnesota Statutes
144.7069 (2005) is published by the
Minnesota Department of Health
thereby providing a forum for hospitals
to share information and learn
from each others errors.
. .
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