To Err Is Human

The Institute of Medicine opened its report on medical error with three cases that had made headlines: Betsy Lehman, a Boston Globe health reporter, killed by a chemotherapy overdose; Willie King, who lost the wrong leg to amputation; and Ben Kolb, eight, who died during minor surgery after a drug mix-up. Such cases, the committee warned, were only the visible part of the problem.

Its estimates came from two large studies of hospital care. Adverse events occurred in 2.9 percent of hospitalizations in Colorado and Utah and in 3.7 percent in New York; 6.6 percent and 13.6 percent of those events led to death, and more than half came from preventable errors. Applied to the 33.6 million US hospital admissions of 1997, the Colorado and Utah figures implied at least 44,000 deaths a year, and the New York figures as many as 98,000. Even the lower number exceeded yearly deaths from motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516). Medication errors alone were thought to cause more than 7,000 deaths a year, and preventable adverse events cost the country an estimated $17 billion to $29 billion.

The Committee on Quality of Health Care in America, chaired by William C. Richardson of the W.K. Kellogg Foundation, dated its preface November 1999; the book, edited by Linda Kohn, Janet Corrigan and Molla Donaldson, carries a 2000 publication date. Its central argument was that the health care system had to be designed for safety at every level, and that building safety into processes of care would reduce errors more than blaming individuals.

The committee laid out four tiers of action: a national focus on safety research and leadership; mandatory reporting of serious errors alongside voluntary reporting; higher standards set by oversight bodies, purchasers and professional groups; and safe practices inside hospitals and clinics. It asked Congress to create a Center for Patient Safety within the Agency for Healthcare Research and Quality, and it said it would be irresponsible to expect anything less than a 50 percent reduction in errors over five years. The agency's Patient Safety Network later wrote that the report placed medical mistakes on the public and professional agenda.