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About

Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern.[1] Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety.[2] The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers and consumers, enhancing error reporting systems, and developing new economic incentives.

To Err is Human

In the United States, the full magnitude and impact of errors in health care was not appreciated until the 1990s, when several reports brought attention to this issue.[3] In 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released a report, To Err is Human: Building a Safer Health System.[4] The IOM called for a broad national effort to include establishment of a Center for Patient Safety, expanded reporting of adverse events, development of safety programs in health care organizations, and attention by regulators, health care purchasers, and professional societies. The majority of media attention, however, focused on the staggering statistics: from 44,000 to 98,000 preventable deaths annually due to medical error in hospitals, 7,000 preventable deaths related to medication errors alone. Within 2 weeks of the report's release, Congress began hearings and President Clinton ordered a government-wide study of the feasibility of implementing the report's recommendations.[5] Initial criticisms of the methodology in the IOM estimates[6] focused on the statistical methods of amplifying low numbers of incidents in the pilot studies to the general population. However, subsequent reports emphasized the striking prevalence and consequences of medical error.

Recently, The College of Healthcare Information Management Executives (CHIME) is urging the federal government to ensure that patients are matched correctly to their health information.[7]

CHIME said it agreed with ONC that, “the accurate and efficient matching of patients to their health information is critical to ensuring patient safety,” and it urged a more focused effort to address patient data matching, saying that, “despite years of development, no clear strategy has emerged to accurately and consistently match patient data.”

References

  1. "World Alliance for Patient Safety". Organization Web Site. World Health Organization. Retrieved 2008-09-27
  2. Patrick A. Palmieri, et al. (2008). "The anatomy and physiology of error in averse healthcare events". Advances in Health Care Management 7: 33–68
  3. Thomas, Eric J. MD, MPH, et al. (2000). "Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado (Abstract)". Medical Care 280 (38): 261–271. doi:10.1097/00005650-200003000-00003. PMID 10718351. Retrieved 2006-06-23.
  4. Kohn, Linda T.; Corrigan, Janet M.; Donaldson, Molla S., eds. (2000). To Err is Human—Building a Safer Health System. Washington, D. C.: National Academies Press. p. 312
  5. Charatan, Fred (2000). "Clinton acts to reduce medical mistakes". BMJ Publishing Group. Retrieved 2006-06-23.
  6. Harold C. Sox, Jr, Steven Woloshin (2000). "How Many Deaths Are Due to Medical Error? Getting the Number Right". Effective Clinical Practice. Retrieved 2006-06-22
  7. Bernie Monegain,. CHIME presses ONC on patient safety. Feb 6, 2013, http://www.healthcareitnews.com/news/chime-presses-onc-patient-safety

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