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PSNet: Patient Safety Network

To Err Is Human: Building a Safer Health System.

Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: National Academy Press; 1999.

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 To Err). 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.