Action on IOM Report The 1999 Institute of Medicine (IOM) report: To err is human: Building a safer health system was a wake up call for both the general public and healthcare providers regarding the...

Introduction
The 1999 report by the Institute of Medicine called for higher patient safety on the wake of
increasing cases of death in hospitals due to human e
or. According to the report, medical
e
ors in the US hospitals caused 44,000 to 98,000 preventable deaths every year. The
amount of associated costs with the preventable deaths was as high as USD 29 billion. Even
though the accuracy of the estimates was questioned, the most conservative estimates clearly
placed the avoidable medical e
ors amongst the leading cause of death in the US. The report
suggested four recommendations for increasing the safety quotient in hospitals in the US.
More than a decade since these four recommendations were tabled, US healthcare has come a
pretty long way – both in terms of safety and efficiency.
Recommendations by IOM
According to the report by IOM, below are the key factors that contribute to the higher
amount of patient deaths in the US due to human e
ors:
 Fragmented and a decentralized health care system creates an unsafe environment for
the patients and also nullifies the efforts taken for increasing patient safety
 Less attention were give to the accreditation and licensing process for preventing
medical e
ors
 The state of the medical liabilities system which discourages the medical staffs and
physicians from admitting their mistakes, thus minimizing the chances of learning
from those e
ors and ensuring that they are not repeated again
 Third party healthcare purchases minimizes the efforts by the healthcare organizations
for improving the patient safety and quality
Thus in order to improve the condition of the healthcare systems, following recommendations
was made:
 Patient Safety Center at AHRQ: It called for the creation of a Center for Patient
Safety which would work towards improving the patient safety across the US. Based
upon the research conducted, the center will evaluate various methods for
identification and prevention of medical e
ors, and thus enhancing patient safety
 E
or-Reporting Systems: It also called for a voluntary and mandatory reporting of
medical e
ors across the state in a standardized format. This will help in fixing those
e
ors, and ensuring these e
ors aren’t repeated again, thus minimizing the events of
deaths due to medical e
ors
 Performance standards: Performance standards relating to patient safety were
explicitly enforced by various groups through accreditation, licensing, and
certifications
 Safety Systems within Health Care Organizations and Patient Responsibility: This
ecommendation called for a stronger leadership for ensuring safe practices are
employed across the organization, and thus e
ors can be limited. It also required the
patient to take an extra onus of knowing the kind of medications they are taking, and
any side effects due to such medications are intimated to the physician
Progress towards IOM recommendations
Within months of the recommendations made in the IOM report, congress called for the
establishment of a Center for Patient Safety to improve patient safety and reduce medical
e
ors. The center received close to USD 250 million every three years, for increasing...