To Err Is Human: Building a Safer Health System

312 Pages·2015·4.92 MB·English

THE NATIONAL ACADEMIES PRESS
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To Err Is Human: Building a Safer Health System
DETAILS
312 pages | 6 x 9 | HARDBACK
ISBN 978-0-309-06837-6 | DOI 10.17226/9728
AUTHORS
BUY THIS BOOK Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on
Quality of Health Care in America, Institute of Medicine
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To Err Is Human: Building a Safer Health System
To Err Is Human
Building a Safer Health System
Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson, Editors
Committee on Quality of Health Care in America
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
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NOTICE: The project that is the subject of this report was approved by the Governing
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the National Academy of Sciences, the National Academy of Engineering, and the Insti-
tute of Medicine. The members of the committee responsible for the report were chosen
for their special competences and with regard for appropriate balance.
Support for this project was provided by The National Research Council and The
Commonwealth Fund. The views presented in this report are those of the Institute of
Medicine Committee on the Quality of Health Care in America and are not necessarily
those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
To err is human : building a safer health system / Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson, editors.
p. cm
Includes bibliographical references and index.
ISBN 0-309-06837-1
1. Medical errors—Prevention. I. Kohn, Linda T. II. Corrigan, Janet. III.
Donaldson, Molla S.
R729.8.T6 2000
362.1—dc21 99-088993
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To Err Is Human: Building a Safer Health System
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Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA
WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg
Foundation, Battle Creek, MI
DONALD M. BERWICK, President and CEO, Institute for Healthcare
Improvement, Boston
J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta
LONNIE R. BRISTOW, Past President, American Medical Association,
Walnut Creek, CA
CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy
Initiatives, General Electric Company, Fairfield, CT
CHRISTINE K. CASSEL, Professor and Chairman, Department of
Geriatrics and Adult Development, Mount Sinai School of Medicine,
New York City
MARK R. CHASSIN, Professor and Chairman, Department of Health Policy,
Mount Sinai School of Medicine, New York City
MOLLY JOEL COYE, Senior Vice President and Director, West Coast
Office, The Lewin Group, San Francisco
DON E. DETMER, Dennis Gillings Professor of Health Management,
University of Cambridge, UK
JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management
Corporation, Boston
BRENT JAMES, Executive Director, Intermountain Health Care, Institute
for Health Care Delivery Research, Salt Lake City, UT
DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health
Plan, Inc., Oakland, CA
LUCIAN LEAPE, Adjunct Professor, Harvard School of Public Health
ARTHUR LEVIN, Director, Center for Medical Consumers, New York City
RHONDA ROBINSON-BEALE, Executive Medical Director, Managed
Care Management and Clinical Programs, Blue Cross Blue Shield of
Michigan, Southfield
JOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University of
California at Irvine College of Medicine
ARTHUR SOUTHAM, Partner, 2C Solutions, Northridge, CA
MARY WAKEFIELD, Director, Center for Health Policy and Ethics,
George Mason University
GAIL L. WARDEN, President and CEO, Henry Ford Health System,
Detroit
v
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Study Staff
JANET M. CORRIGAN, Director, Division of Health Care Services,
Director, Quality of Health Care in America Project
MOLLA S. DONALDSON, Project Co-Director
LINDA T. KOHN, Project Co-Director
TRACY McKAY, Research Assistant
KELLY C. PIKE, Senior Project Assistant
Auxiliary Staff
MIKE EDINGTON, Managing Editor
KAY C. HARRIS, Financial Advisor
SUZANNE MILLER, Senior Project Assistant
Copy Editor
FLORENCE POILLON
vi
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Reviewers
his report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with
Tprocedures approved by the National Research Council’s Report Re-
view Committee. The purpose of this independent review is to provide can-
did and critical comments that will assist the Institute of Medicine in mak-
ing the published report as sound as possible and to ensure that the report
meets institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and the draft manuscript remain
confidential to protect the integrity of the deliberative process. The commit-
tee wishes to thank the following individuals for their participation in the
review of this report:
GERALDINE BEDNASH, Executive Director, American Association of
Colleges of Nursing, Washington, DC
PETER BOUXSEIN, Visiting Scholar, Institute of Medicine, Washington,
DC
JOHN COLMERS, Executive Director, Maryland Health Care Cost and
Access Commission, Baltimore
JEFFREY COOPER, Director, Partners Biomedical Engineering Group,
Massachusetts General Hospital, Boston
ROBERT HELMREICH, Professor, University of Texas at Austin
vii
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
viii REVIEWERS
LOIS KERCHER, Vice President for Nursing, Sentara-Virginia Beach
General Hospital, Virginia Beach, VA
GORDON MOORE, Associate Chief Medical Officer, Strong Health,
Rochester, NY
ALAN NELSON, Associate Executive Vice President, American College of
Physicians/American Society of Internal Medicine, Washington, DC
LEE NEWCOMER, Chief Medical Officer, United HealthCare Corporation,
Minnetonka, MN
MARY JANE OSBORN, University of Connecticut Health Center
ELLISON PIERCE, Executive Director, Anesthesia Patient Safety
Foundation, Boston
Although the individuals acknowledged have provided valuable com-
ments and suggestions, responsibility for the final contents of the report
rests solely with the authoring committee and the Institute of Medicine.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Preface
o Err Is Human: Building a Safer Health System. The title of this
report encapsulates its purpose. Human beings, in all lines of work,
Tmake errors. Errors can be prevented by designing systems that make
it hard for people to do the wrong thing and easy for people to do the right
thing. Cars are designed so that drivers cannot start them while in reverse
because that prevents accidents. Work schedules for pilots are designed so
they don’t fly too many consecutive hours without rest because alertness and
performance are compromised.
In health care, building a safer system means designing processes of care
to ensure that patients are safe from accidental injury. When agreement has
been reached to pursue a course of medical treatment, patients should have
the assurance that it will proceed correctly and safely so they have the best
chance possible of achieving the desired outcome.
This report describes a serious concern in health care that, if discussed
at all, is discussed only behind closed doors. As health care and the system
that delivers it become more complex, the opportunities for errors abound.
Correcting this will require a concerted effort by the professions, health care
organizations, purchasers, consumers, regulators and policy-makers. Tradi-
tional clinical boundaries and a culture of blame must be broken down. But
most importantly, we must systematically design safety into processes of care.
This report is part of larger project examining the quality of health care
ix
Copyright National Academy of Sciences. All rights reserved.