![]() 11 In fact, the number of hospital-acquired conditions fell from 145 per 1,000 admissions in 2010 to 115 per 1,000 admissions in 2015, as assessed by the AHRQ national scorecard. Improved hand washing has also been an important part of this effort. Nearly all hospitals have implemented surveillance for the main types of hospital-acquired infections, including these two conditions, central line–associated bloodstream infections, and surgical site infections. Subsequent safety targets included ventilator-associated pneumonia and catheter-associated urinary tract infection. Some of the principles behind such interventions were adopted from high-reliability industries 10 such as aviation, which use a more systematic approach to safety than health care does. 9 This resulted in a change in how people thought about harm, because even in situations in which no obvious error had been made, it was possible to dramatically reduce the risk of harm. Many felt that these initial results might be too good to be true, but Pronovost and colleagues were later able to replicate the results across the state of Michigan. 8 The bundle included steps to follow in central venous catheter insertion, the handling and maintenance of lines, and the prompt removal of unnecessary lines. Peter Pronovost and his team from Johns Hopkins University showed that by following a bundle of safety procedures, they could reduce the incidence of these infections to nearly zero. Central line–associated bloodstream infections (a type of hospital-acquired infection) represent a notable example. Before the report, adverse events such as hospital-acquired infections were considered a cost of doing business. ![]() ![]() However, many experts believe that the number is probably in the hundreds of thousands annually, while many more patients are injured unnecessarily.Įarly efforts to reduce hospital errors largely focused on hospital safety. 4 – 7 This is partly because methodologically questionable approaches have been used to estimate deaths, and in any given instance, it’s often hard to determine whether an individual death could have been prevented. The exact number of deaths that occur in the US is highly controversial and has been debated at some length. In the years since the report’s publication, it has become increasingly clear that safety issues are pervasive throughout health care and that patients are frequently injured as a result of the care they receive. This progress could lead us from a Bronze Age of rudimentary tool development to a Golden Era of vast improvement in patient safety. With the increasing availability of electronic data, investments must now be made in developing and testing methods to routinely and continuously measure the frequency and types of patient harm and even predict risk of harm for specific patients. In sum, the frequency of preventable harm remains high, and new scientific and policy approaches to address both prior and emerging risk areas are imperative. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. Progress in addressing other hospital-acquired adverse events has been variable. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. The Institute of Medicine’s To Err Is Human, published in 1999, represented a watershed moment for the US health care system.
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