R L Sirota1. 1. Department of Pathology, West Suburban Hospital Medical Center, Oak Park, IL 60302, USA.
Abstract
CONTEXT: During the past several years, more attention has been focused on the topics of medical error and patient safety than in the past. At the end of 1999, the Institute of Medicine (IOM) published a seminal report concerning medical error in the United States; this report will have sweeping implications for all disciplines of medicine, including pathology. OBJECTIVE: To review the major findings of the IOM report on medical error and to discuss their implications for the field of pathology. METHODS: Review of the IOM report on medical error and discussion of other relevant literature on medical error. RESULTS: The IOM report on medical error highlights an unacceptable rate of medical error in the United States and mandates a 50% reduction in medical error during the next 5 years. It recommends regulatory solutions to this problem, as well as organizational approaches to error reduction. It proposes both mandatory and voluntary systems for reporting of medical error. The report suggests that systems should be examined for latent flaws and that individual culpability for error should not be overemphasized. The report recommends that error-reduction strategies that have been applied to other industries should be studied and that known concepts of error reduction should be applied to medicine. Strategies that the IOM suggests can be applied to pathology. CONCLUSIONS: Medical error occurs at an unacceptably high rate. Recommendations made in the IOM report on medical error and patient safety should be applied to the practice of pathology.
CONTEXT: During the past several years, more attention has been focused on the topics of medical error and patient safety than in the past. At the end of 1999, the Institute of Medicine (IOM) published a seminal report concerning medical error in the United States; this report will have sweeping implications for all disciplines of medicine, including pathology. OBJECTIVE: To review the major findings of the IOM report on medical error and to discuss their implications for the field of pathology. METHODS: Review of the IOM report on medical error and discussion of other relevant literature on medical error. RESULTS: The IOM report on medical error highlights an unacceptable rate of medical error in the United States and mandates a 50% reduction in medical error during the next 5 years. It recommends regulatory solutions to this problem, as well as organizational approaches to error reduction. It proposes both mandatory and voluntary systems for reporting of medical error. The report suggests that systems should be examined for latent flaws and that individual culpability for error should not be overemphasized. The report recommends that error-reduction strategies that have been applied to other industries should be studied and that known concepts of error reduction should be applied to medicine. Strategies that the IOM suggests can be applied to pathology. CONCLUSIONS: Medical error occurs at an unacceptably high rate. Recommendations made in the IOM report on medical error and patient safety should be applied to the practice of pathology.
Authors: Peter Banks; Richard Brown; Alex Laslowski; Yvonne Daniels; Phil Branton; John Carpenter; Richard Zarbo; Ramses Forsyth; Yan-Hui Liu; Shane Kohl; Joachim Diebold; Shinobu Masuda; Tim Plummer; Eslie Dennis Journal: Lab Med Date: 2017-05-01