Free Executive Summary
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 ISBN: 0-309-06837-1, 312 pages, 6 x 9, hardback (2000)
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As many as 98,000 people die each year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer and AIDS--making medical errors the fifth leading cause of death in this country. The Institute of Medicine now spearheads an initiative to improve the quality of care in America by focusing on the facts and making wide-ranging recommendations. Central to the ideas proposed by the IOM is the notion that skilled and caring professionals can--and do--make mistakes because, after all, to err is human. This is why it is vital that we put this issue at the top of our national agenda and seek ways to reduce these errors through the design of a safer health system.
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References: 1. Cook, Richard; Woods, David; Miller, Charlotte, A Tale of Two Stories: Contrasting Views of Patient Safety. Chicago: National Patient Safety Foundation, 1998. 2. Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. See also: Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring 2000. 3. American Hospital Association. Hospital Statistics. Chicago. 1999. See also: Thomas, Eric J.; Studdert, David M.; Burstin, Helen R., et al. Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado. Med Care forthcoming Spring 2000. See also: Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. 4. American Hospital Association. Hospital Statistics. Chicago. 1999. See also: Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 324:370–376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. 5. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final Data for 1997. National Vital Statistics Reports. 47(19):27, 1999. 6. Centers for Disease Control and Prevention (National Center for Health Statistics). Births and Deaths: Preliminary Data for 1998. National Vital Statistics Reports. 47(25):6, 1999. 7. Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. See also: Johnson, W.G.; Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu To Err Is Human: Building a Safer Health System http://books.nap.edu/catalog/9728.html 16 TO ERR IS HUMAN Brennan, Troyen A.; Newhouse, Joseph P., et al. The Economic Consequences of Medical Injuries. JAMA. 267:2487–2492, 1992. 8. Occupational Safety and Health Administration. The New OSHA: Reinventing Worker Safety and Health [Web Page]. Dec. 16, 1998. Available at: www.osha.gov/ oshinfo/reinvent.html. 9. Phillips, David P.; Christenfeld, Nicholas; and Glynn, Laura M. Increase in US Medication-Error Deaths between 1983 and 1993. The Lancet. 351:643–644, 1998. 10. Bates, David W.; Spell, Nathan; Cullen, David J., et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 277:307–311, 1997. 11. Leape, Lucian; Brennan, Troyen; Laird, Nan; et al., The Nature of Adverse Events in Hospitalized Patients, Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377–384, 1991. 12. Milstein, Arnold, presentation at “Developing a National Policy Agenda for Improving Patient Safety,” meeting sponsored by National Patient Safety Foundation, Joint Commission on Accreditation of Health Care Organizations and American Hospital Association, July 15, 1999, Washington, D.C. 13. Veatch, Robert M., Cross-Cultural Perspectives in Medical Ethics: Readings. Boston: Jones and Bartlett Publishers, 1989. 14. Reason, James T., Human Error, Cambridge: Cambridge University Press, 1990. 15. Deming, W. Edwards, Out of the Crisis, Cambridge: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1993. 16. Berwick, Donald M. and Leape, Lucian L. Reducing Errors in Medicine. BMJ. 319:136–137, 1999. 17. Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng J Med. 324(6):370–376, 1991. See also: Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. 18. Thomas, Eric J.; Studdert, David M.; Newhouse, Joseph P., et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 36:255–264, 1999. Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu