To Err is Human: 15 Years Later

Submitted by on Friday, November 28, 2014 - 08:16

Tomorrow marks the 15th anniversary of the release of "To Err Is Human" – As the traditional year-end celebrations get kicked off and we take stock of what we have been able to accomplish, both individually and collectively, we should all take a seriously introspective look at the lasting effect of this important report. As the first in the series of the Quality of Care in the U.S., To Err Is Human laid out a compelling case that an industry whose professionals were educated and trained to help heal the sick had to focus on healing the industry itself. The error rate, expressed in the underuse of needed services, the overuse of unneeded services, and the harm from misuse of services was staggering. And faced with the evidence, most on the inside cried foul and denied the gravity of the situation, while policymakers took bi-partisan action to address the issues. From that flurry of activity came a voluntary hospital quality reporting program, which then turned more or less mandatory. The Leapfrog Group emerged from the willingness of large employers to demand safer care from hospitals that treat their employees. Pay-for-performance came out as a mechanism to counter the disastrous effects of plain vanilla fee-for-service. And since then, the movement around accountability and value-based purchasing has simply continued to gain steam. In fifteen years, the industry has changed.

What this means to you – The gratitude of the country to the authors and advisors of the report should continue unabated, and so should the vigilance of employers and policymakers. The vast majority of hospitals in the U.S. continue to receive far less than an A on Leapfrog's Hospital Safety Score. The quality measures that are collected and reported on Hospital Compare are all but useless in differentiating performance. The lack of medical record information sharing creates waste in resources and harms patients. There's no question that the industry has responded to a general call to action, and that many hospitals and health systems are deeply engaged in clinical pathway re-engineering, trying to optimize patient outcomes. But it's also easy to become complacent, to believe that the progress made is good enough, when it isn't. In fifteen years, the entire telecommunications industry was revamped. During the same period of time, new industries have emerged which have yielded tremendous benefits to consumers. The fact is that the pace of change in health care has been too slow and that lack of speed has been measured in tens of thousands of human lives lost to errors. Even if to err is indeed quite human, the error rate can and should be brought significantly down. That's the task at hand and there's no reason it should take another fifteen years.