Literature DB >> 16751466

The "To Err is Human" report and the patient safety literature.

H T Stelfox1, S Palmisani, C Scurlock, E J Orav, D W Bates.   

Abstract

BACKGROUND: The "To Err is Human" report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards.
METHODS: We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995-2004.
RESULTS: A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. The rate of patient safety publications increased from 59 to 164 articles per 100,000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles. Publications of original research increased from an average of 24 to 41 articles per 100,000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100,000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v 2%, p<0.001) while organizational culture was the most frequent subject (1% v 5%, p<0.001) after publication of the report.
CONCLUSIONS: Publication of the report "To Err is Human" was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.

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Year:  2006        PMID: 16751466      PMCID: PMC2464859          DOI: 10.1136/qshc.2006.017947

Source DB:  PubMed          Journal:  Qual Saf Health Care        ISSN: 1475-3898


  17 in total

1.  Learning from our mistakes: quality grand rounds, a new case-based series on medical errors and patient safety.

Authors:  Robert M Wachter; Kaveh G Shojania; Sanjay Saint; Amy J Markowitz; Mark Smith
Journal:  Ann Intern Med       Date:  2002-06-04       Impact factor: 25.391

Review 2.  Pushing the profession: how the news media turned patient safety into a priority.

Authors:  M L Millenson
Journal:  Qual Saf Health Care       Date:  2002-03

3.  A series on patient safety.

Authors:  Lucian Leape; Arnold M Epstein; Mary Beth Hamel
Journal:  N Engl J Med       Date:  2002-10-17       Impact factor: 91.245

4.  Segmented regression analysis of interrupted time series studies in medication use research.

Authors:  A K Wagner; S B Soumerai; F Zhang; D Ross-Degnan
Journal:  J Clin Pharm Ther       Date:  2002-08       Impact factor: 2.512

5.  The patient safety movement will help, not harm, quality.

Authors:  Robert M Wachter; Kaveh G Shojania
Journal:  Ann Intern Med       Date:  2004-08-17       Impact factor: 25.391

6.  Improving patient safety--five years after the IOM report.

Authors:  Drew E Altman; Carolyn Clancy; Robert J Blendon
Journal:  N Engl J Med       Date:  2004-11-11       Impact factor: 91.245

7.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

Authors:  L L Leape; T A Brennan; N Laird; A G Lawthers; A R Localio; B A Barnes; L Hebert; J P Newhouse; P C Weiler; H Hiatt
Journal:  N Engl J Med       Date:  1991-02-07       Impact factor: 91.245

8.  The Quality in Australian Health Care Study.

Authors:  R M Wilson; W B Runciman; R W Gibberd; B T Harrison; L Newby; J D Hamilton
Journal:  Med J Aust       Date:  1995-11-06       Impact factor: 7.738

9.  The end of the beginning: patient safety five years after 'to err is human'.

Authors:  Robert M Wachter
Journal:  Health Aff (Millwood)       Date:  2004 Jul-Dec       Impact factor: 6.301

Review 10.  Patient safety is not enough: targeting quality improvements to optimize the health of the population.

Authors:  Steven H Woolf
Journal:  Ann Intern Med       Date:  2004-01-06       Impact factor: 25.391

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  66 in total

Review 1.  Frequency and Nature of Medication Errors and Adverse Drug Events in Mental Health Hospitals: a Systematic Review.

Authors:  Ghadah H Alshehri; Richard N Keers; Darren M Ashcroft
Journal:  Drug Saf       Date:  2017-10       Impact factor: 5.606

2.  Beyond patient safety Flatland.

Authors:  Jeffrey Braithwaite; Enrico Coiera
Journal:  J R Soc Med       Date:  2010-05-14       Impact factor: 5.344

Review 3.  Medical care and drug-related problems: Do doctors and pharmacists speak the same language?

Authors:  J W Foppe van Mil; Tommy Westerlund; Lawrence Brown; Timothy F Chen; Martin Henman; Kurt Hersberger; James McElnay; Martin Schulz
Journal:  Int J Clin Pharm       Date:  2016-01-21

4.  A perinatal care quality and safety initiative: are there financial rewards for improved quality?

Authors:  Katy B Kozhimannil; Samantha A Sommerness; Phillip Rauk; Rebecca Gams; Charles Hirt; Stanley Davis; Kristi K Miller; Daniel V Landers
Journal:  Jt Comm J Qual Patient Saf       Date:  2013-08

5.  Telephone interpreter discrepancies: videotapes of Hmong medication consultations.

Authors:  Maichou Lor; Betty Chewning
Journal:  Int J Pharm Pract       Date:  2015-08-27

Review 6.  Medication errors in critical care: risk factors, prevention and disclosure.

Authors:  Eric Camiré; Eric Moyen; Henry Thomas Stelfox
Journal:  CMAJ       Date:  2009-04-28       Impact factor: 8.262

7.  The birth of neurohospitalists.

Authors:  William D Freeman; S Andrew Josephson
Journal:  Neurohospitalist       Date:  2011-01

8.  A system approach to dispensing errors: a national study on perceptions of the Finnish community pharmacists.

Authors:  Tuula Teinilä; Virpi Grönroos; Marja Airaksinen
Journal:  Pharm World Sci       Date:  2008-06-24

9.  A model for medication safety event detection.

Authors:  Rita A Snyder; Willa Fields
Journal:  Int J Qual Health Care       Date:  2010-03-27       Impact factor: 2.038

10.  Safe healthcare: we're running out of excuses.

Authors:  David P Stevens
Journal:  Postgrad Med J       Date:  2010-03       Impact factor: 2.401

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