Question

Give a summary of the "To Err is Human" report

Answer 1

Ans) The report of the Institute of Medicine published in December 1999 is a groundbreaking aggressive report about errors in medicine and how to improve patient safety. The core elements are of significant relevance for anaesthesiologists.

- Adverse Events (AE) occur in 3-4% of all hospital admissions. Over 50% of AE are due to medical errors and could have been prevented theoretically! Approximately 10% of AE lead to death. If the numbers of two studies are extrapolated to all US admissions 44 000-98 000 Americans die each year due to errors. Taking these numbers into account, medical errors are the 8th leading cause of death in the US (breast cancer: 42 000 deaths).

- The costs are estimated to be 17-29 billions a year. The report wants to break the cycle of inaction. Envisaged is a 50% reduction of AE in the next 5 years. This seems possible because the know-how exists to prevent many of these mistakes. Health care is just a decade or more behind other high-risk industries in its attention to ensuring basic safety. This means that dramatic, system-wide changes are required.

- The report recommends: The focus must shift from blaming individuals to preventing future errors by designing safety into the system. Establishing a national Patient Safety Center to enhance the knowledge base about safety. Implementing periodic reexaminations and re-licensing. Paying special attention to the safe use of drugs and using proven medication safety practices. Designing of reporting systems: mandatory and public for severe injuries and deaths; voluntary and protected for minor injuries and incidents. Raising standards and expectations for safety issues and creating a safety culture: Safety as a declared serious aim, interdisciplinary team training programs and the use of simulators ('proven method') whenever possible.

- Finally the efforts should lead to safe practices at the delivery level, because 'it may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet the challenges ahead'.