The patient safety story

Abstract

What we know The catalyst came from the United States. By 1998 some opinion leaders in health care were frustrated by the lack of attention given to addressing serious quality challenges. An extensive review of the literature on quality, conducted by RAND Health, documented shortcomings in both safety and effectiveness.5 Expert panels, one convened by the Institute of Medicine and another established by the President of the United States, recommended that improving healthcare quality should become a national priority.6 7 But despite the strong, convincing evidence and recommendations from expert panels, the “quality problem” never made it on to the national agenda. In another effort to bring the issues to the fore-front, the Institute of Medicine established its quality of care in America committee. In late 1999 the committee's first report, To Err is Human, was released.8 Unlike previous reports on quality, which had been directed at elected representatives, healthcare leaders, and professionals, the key audience for this report was the lay public. In effect, it was direct marketing to patients about medical errors. The impact was tangible, with near saturation coverage in the media for almost three days. The United Kingdom responded with its own analysis, An Organisation with a Memory.9 There are many lessons here. Firstly, targeting the public made the issue visible and widened the debate. Secondly, and just as important, was the clarity of the message. Errors are something that everyone can understand. People are familiar with “accidents” and efforts to avoid them. There are parallels in air and road transport; indeed in these services there are institutions to protect the public. Thirdly, the report focused primarily on errors of execution—events that no one intended to happen and where there is wide agreement that something went wrong.8 This level of consensus is qualitatively different from discussions about other quality issues, such as medical effectiveness, where there is often disagreement about what constitutes evidence based practice, or the applicability of the evidence to particular patients and circumstances. Fourthly, the report made it clear that more people die as a result of medical errors than from other common causes of death including motor vehicle crashes, breast cancer, and AIDS. The case was therefore made for giving attention and resources commensurate with the scale of the problem.