Author Affiliations: Department of Health Policy
and Management, Harvard School of Public Health, Boston (Dr Leape); and the
Institute for Healthcare Improvement, Cambridge, and Department of Pediatrics,
Harvard Medical School, Boston (Dr Berwick), Mass.
Five years ago, the Institute of Medicine (IOM) called for a national
effort to make health care safe. Although progress since then has been slow,
the IOM report truly “changed the conversation” to a focus on
changing systems, stimulated a broad array of stakeholders to engage in patient
safety, and motivated hospitals to adopt new safe practices. The pace of change
is likely to accelerate, particularly in implementation of electronic health
records, diffusion of safe practices, team training, and full disclosure to
patients following injury. If directed toward hospitals that actually achieve
high levels of safety, pay for performance could provide additional incentives.
But improvement of the magnitude envisioned by the IOM requires a national
commitment to strict, ambitious, quantitative, and well-tracked national goals.
The Agency for Healthcare Research and Quality should bring together all stakeholders,
including payers, to agree on a set of explicit and ambitious goals for patient
safety to be reached by 2010.
Leape LL, Berwick DM. Five Years After To Err Is Human What Have We Learned?. JAMA. 2005;293(19):2384-2390. doi:10.1001/jama.293.19.2384