Institute of Medicine Report
The Institute of Medicine (IOM) Report, "To Err is Human: Building a Safer Health System", was released in November, 1999 and served to highlight the seriousness of medical errors in health care. The IOM Report indicated that at least 44,000 Americans die each year as a result of medical errors and may be as high as 98,000. Even when using the lower estimate, more people die in a given year from medical errors than from motor vehicle accidents, breast cancer or AIDS. And, the above estimates do not include any deaths resulting from medical errors in non-hospital settings (e.g., physicians' offices, home care).
What is an Error?
The IOM Report defines an error as "the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning)". Errors can occur in all stages and processes of care from diagnosis to treatment to preventive care. Medication-related errors, for example, occur in both hospitals and out-of-hospital settings. Surgeons operate on wrong sites or wrong sides of patients. Anesthesia can be incorrectly administered.
The IOM Report emphasized that most medical errors occur as the result of failures of complex medical systems and not individual negligence or incompetence. Therefore, patient safety must be built into processes of care such as standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be responsible for many errors. Also, much can be learned from the analysis of errors. All serious injuries or deaths should be thoroughly evaluated to identify improvements in the system that can be made to reduce the risk of similar events happening in the future.