In 2000, the Institute of Medicine, an arm of the National Academies of Science, issued its bellwether report, "To Err Is Human," and the concept of medical errors and patient safety became a national cause celebre. That publication estimated that 98,000 people die in any given year from medical errors that occur in hospitals. Other reports in the medical literature estimate that as many as 180,000 deaths occur in the United States each year due to errors in medical care, many of which are preventable.
Patient safety advocates and researchers argue that only by viewing the health care continuum as a system can truly meaningful improvements be made. These advocates argue that a systems approach that emphasizes prevention, not punishment is the best method to accomplish this goal. Other high-risk industries/companies such as airlines and nuclear power have used this approach to accomplish safety.
To make the prevention effort effective, standardized methods of gathering and analyzing data from the field that allow the formation of the most accurate picture possible are being introduced to the health care setting. Many health care organizations have developed teams that review data to determine problems, formulate solutions, test, implement, and measure outcomes in order to improve patient safety. Findings from the teams are shared nation-wide. These organizations follow principals that presume that people do not come to work to do a bad job or make an error, but given the right set of circumstances any provider can make a mistake. They view as "the easy answer" that it was someone’s fault, and focus on answering what they view as the "tougher question" as to why the error occurred. It is seldom a single reason. Through understanding the real underlying causes organizations believe they can better position ourselves to prevent future occurrences.
Nationally, accrediting, teaching and other organizations are amassing databases of errors, called "sentinel events" or "medical errors" in order to assist organizations in taking advantage of the experience of others and advocating patient safety systems in areas where the most risk seems to exist.
Establishing a culture of safety where people are able to report both adverse events and close calls without fear of punishment is viewed by many as the the key to creating patient safety. But where does this leave licensing boards, whose focus is on assessing and punishing individual providers? How do they fit into the patient safety scheme?
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