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Patient Safety at Ten: Unmistakable Progress, Troubling Gaps



December 2nd, 2009

Ten years ago, the Institute of Medicine released To Err Is Human, a much-discussed report that launched the modern patient-safety movement.  Evaluating what has been accomplished in a Health Affairs Web First article published yesterday, Robert Wachter, author of two books on patient safety and editor of the federal government’s two leading safety Web sites, gives efforts an overall grade of B-, a slight improvement from his grade of C+ in a similar analysis five years ago.

Overall, the decade has seen progress in hospitals’ responses to pressures (accreditation, regulation, and error reporting), but health information technology (IT) has lagged behind, with research in the area advancing but underfunded, according to Wachter, professor and associate chair in the Department of Medicine at the University of California, San Francisco. 

In his analysis, Wachter looks at a multitude of categories. The highest grade, an A-, was given to organizational interventions thanks to what Wachter describes as stronger engagement by governments and NGOs at the federal, state, and global levels.  Several areas received grades of C+, including health IT, which received a higher grade of B- in 2004. Wachter sees an almost static situation and “increasing evidence of health IT-related safety hazards and implementation challenges.” However, with funds directed to health IT through the Obama stimulus package, he anticipates future improvements in this area.

Wachter cites several early missteps in the patient safety field, including the implementation of residency duty-hour reductions without an attempt to improve procedures when residents sign out, and the national requirement to implement medication reconciliation in the absence of clear guidelines regarding how to accomplish this goal safely.  Despite these setbacks, Wachter concludes that most changes have constituted real progress: “Even our missteps…have yielded valuable lessons.” 

Moreover, given the massive complexity of the health care system, he writes, “Had I been asked in 1999 how much change in patient safety-related areas would be possible within a decade, I would have substantially underestimated our actual accomplishments.”

More on Wachter’s article can be found on the blog of the Interdisciplinary Nursing Quality Research Initiative, a project of the Robert Wood Johnson Foundation.  A post on the article appears as part of a two-week series commemorating the ten-year anniversary of To Err Is Human.

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    December 3rd, 2009 at 11:02 am

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