To Err is Human, but This is Something Else.

by John Ratkowitz
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In November 1999, the Institute of Medicine (IOM), a branch of the National Academy of Sciences, published a study that declared that a threshold improvement in the quality of health care was urgently needed because medical negligence committed in hospitals in the United States was killing more people annually than motor vehicle accidents, breast cancer and AIDS. Kohn LT, et al., To Err Is Human: Building a Safer Health System, National Academy Press pg. 26 (1999). (Hereafter "To Err is Human"). The impact of that study, and its "jarring" analogy that the annual number of deaths from hospital negligence would be equal to the downing of a jumbo jet every single day, "galvanized the public and health professionals and led to congressional hearings, media exposes, and millions of anxious patients." Robert M. Wachter, M.D., The End of the Beginning: Patient Safety Five Years After "To Err Is Human," W4 Health Aff. (Millwood) Web Exclusives 534 (2004). (Hereafter "The End of the Beginning"). It is not an overstatement to say that as a result of the IOM study, in 1999 the United States came to the realization that medical mistakes were a problem of epidemic proportions. Id.

There was an initial flurry of activity following the IOM report in 1999. Id. Five years after the study was released, the federal government, private foundations, health plans, hospitals and clinics were all investing more in patient safety then they had in 1999. The End of the Beginning supra, at 543. Notwithstanding, as early as 2004, there was recognition that efforts to advance patient safety were not moving forward comprehensively enough to be responsive to the problem. Id.

Various reasons have been given for loss of momentum in the patient safety movement over the last ten years. First, there was no organization set up to implement and oversee the plans set forth in To Err is Human. 10 Years, 5 Voices 1 Challenge, supra, at 28. Additionally, the health care industry has displayed a reluctance to engage in recommended error reporting systems. Id. Although we are beginning to see changes, for the most part, payment systems throughout the last ten years generally did not reward patient safety or penalize unsafe practices. Id. at 27. Finally:

Some of this lack of progress may be attributable to the persistence of a medical ethos, institutionalized in the hierarchal structure of academic medicine and healthcare organizations, that discourages teamwork and transparency and undermines the establishment of clear systems of accountability for safe care.

Transforming Healthcare, a Safety Imperative, supra, at 424.

On November 18, 2010, the New England Journal of Medicine published a study that attempted to quantify the impact of patient safety measures on in-patient hospital admissions. Christopher P. Landrigan, M.D. et al., Temporal Trends in Rates of Patient Harm resulting from Medical Care, 363 New Eng. J. Med. 2124 (2010). (Hereafter "Trends in Rates of Patient Harm"). The New York Times identified Trends in Rates of Patient Harm as "one of the most rigorous efforts to collect data about patient safety" since the publication of To Err is Human. Denise Grady, Study Finds No Progress in Safety at Hospitals, N.Y. Times, November 24, 2010 at A1. As the title to Ms. Grady's article suggests, the study published on November 18, 2010 demonstrated that despite the urgency of the problem, no progress has been made to reduce in-patient hospital errors.

This article discusses the morality of calls for tort reform to limit the rights of medical malpractice victims in light of the lack of improvement in reducing preventable medical errors.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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