K W Kizer1. 1. The National Quality Forum, Washington, DC, USA. kenneth.kizer@qualityforum.org.
Abstract
OBJECTIVE: The Institute of Medicine (IOM) and the Presidential Advisory Commission on Consumer Protection and Quality in the Healthcare Industry have both recently highlighted healthcare errors as a serious public health problem. An in-depth review of the issue was conducted by the National Quality Forum (NQF) in preparation for work the federal government has asked the NQF to do. PARTICIPANTS: The membership of the NQF includes a wide array of public and private health agencies, healthcare provider organizations, consumer groups, healthcare purchasers, and research and quality improvement organizations. EVIDENCE: Published literature, including more than 350 journal articles and over 30 books and monographs, were reviewed, and input was solicited from individuals and organizations known to be knowledgeable on the topic, including the Harvard University Executive Session on Medical Error, the VA National Patient Safety Center, the Joint Commission on Accreditation of Healthcare Organizations, the National Patient Safety Foundation, and the IOM. The principal observations and findings were collated; 10 high-priority strategic areas needing action were identified; and specific recommendations for each area were crafted. CONSENSUS PROCESS: A draft statement was prepared and submitted to the NQF membership and Directors, as well as to external reviewers. The statement was revised following subsequent rounds of review and comment, after which it was approved by the NQF Board of Directors. CONCLUSIONS: There is an urgent need to reduce healthcare errors; however, numerous barriers impede progress in this regard, including widespread misunderstanding about why healthcare errors occur, the prevailing culture of "name and blame" surrounding these events, lack of user-friendly error-reporting mechanisms, and fear of litigation if errors are acknowledged and reported. To eliminate these barriers, and to begin to reduce healthcare errors, the NQF recommends that concerted action be taken in the 10 strategic areas identified here.
OBJECTIVE: The Institute of Medicine (IOM) and the Presidential Advisory Commission on Consumer Protection and Quality in the Healthcare Industry have both recently highlighted healthcare errors as a serious public health problem. An in-depth review of the issue was conducted by the National Quality Forum (NQF) in preparation for work the federal government has asked the NQF to do. PARTICIPANTS: The membership of the NQF includes a wide array of public and private health agencies, healthcare provider organizations, consumer groups, healthcare purchasers, and research and quality improvement organizations. EVIDENCE: Published literature, including more than 350 journal articles and over 30 books and monographs, were reviewed, and input was solicited from individuals and organizations known to be knowledgeable on the topic, including the Harvard University Executive Session on Medical Error, the VA National Patient Safety Center, the Joint Commission on Accreditation of Healthcare Organizations, the National Patient Safety Foundation, and the IOM. The principal observations and findings were collated; 10 high-priority strategic areas needing action were identified; and specific recommendations for each area were crafted. CONSENSUS PROCESS: A draft statement was prepared and submitted to the NQF membership and Directors, as well as to external reviewers. The statement was revised following subsequent rounds of review and comment, after which it was approved by the NQF Board of Directors. CONCLUSIONS: There is an urgent need to reduce healthcare errors; however, numerous barriers impede progress in this regard, including widespread misunderstanding about why healthcare errors occur, the prevailing culture of "name and blame" surrounding these events, lack of user-friendly error-reporting mechanisms, and fear of litigation if errors are acknowledged and reported. To eliminate these barriers, and to begin to reduce healthcare errors, the NQF recommends that concerted action be taken in the 10 strategic areas identified here.
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