To Err Is Human: Building a Safer Health System.
Kohn L, Corrigan J, Donaldson M, eds. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
One measure of the impact of this report, the first in the series of reports by the Institute of Medicine (IOM) on the quality of health care in the United States, is that one can still refer to “The IOM Report” and everyone will recognize the reference to
To Err is Human
(despite the fact that, as of this writing, the IOM has released approximately 250 reports since
). In fact, many argue that the modern field of patient safety began with this report’s publication. Although the report has been criticized for its strong focus on medication errors and computerized order entry (to the exclusion of other safety concerns) and the relatively limited discussion of the impact of the malpractice system, there is no mistaking its impact. Perhaps its most famous contribution was the extrapolation of the
Harvard Medical Practice Study
data and the
Utah and Colorado Medical Practice Study
data, which led to the famous estimate of 44,000 to 98,000 deaths per year from medical errors (the equivalent of a jumbo jet a day). Whether one believes these numbers or not, it is clear that the IOM report was essential in placing the issue of medical mistakes on the public and professional agenda.
Executive summary (PDF)
Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.
Bovbjerg RR, Tancredi LR. J Law Med Ethics. 2005;33:478-500.
The Perruche case and the issue of compensation for the consequences of medical error.
Costich JF. Health Policy. 2006;78:8-16.
In a crisis, do-not-revive requests don't always work.
Parker L. USA Today. December 19, 2006.
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