It has been 15 years since the Institute of Medicine (IOM) released its seminal report, “To Err is Human,” which captured the attention of the world with its estimate that medical errors cause 44,000 to 98,000 deaths per year. This report played a critical role in raising awareness about errors and started an important national dialogue that continues today.

A new article in BMJ Quality & Safety, Fifteen Years After To Err Is Human, reviews the progress made since the original IOM report and notes the difficulties in reducing harm, including a lack of robust mechanisms to routinely measure the problem and widely varying estimates of magnitude.

One exception is that of central line-associated bloodstream infection (CLABSI). The authors cite the reduction of CLABSI rates since the IOM report as a case study in the success of reducing infection, with intensive care unit (ICU) CLABSI rates dropping nationwide over the past decade. Elements considered critical to the national success in reducing CLABSI rates include these:

  • reliable and valid measurement systems
  • evidence-based care practices
  • investment in implementation sciences
  • local ownership and peer learning communities
  • alignment in efforts around common goal and measures

At a recent symposium by the National Academy of Medicine, a diverse set of panelists discussed the original IOM report and future patient safety priorities for reform within payment systems, governance and leadership, and academia. The archived webcast of the symposium is available online.

Contact Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.