The Institute of Medicine (IOM) report To Err Is Human1 converted an issue of growing professional
awareness to one of substantial public concern in a manner and pace unprecedented
in modern experience with matters of health care quality. The epidemiologic
finding that more than 1 million injuries and nearly 100 000 deaths occur
in the United States annually as a result of mistakes in medical care came
from studies nearly a decade old, but it was new information for the public,
and it resonated strongly. In short order, the US Congress initiated hearings
and the president ordered a government-wide feasibility study, which led to
a subsequent directive to governmental agencies to implement the recommendations
of the IOM report. The IOM called on all parties to make improving patient
safety a national priority. In response, physicians, hospitals, and health
care organizations have been searching for safe practices and asking what
they should do to make health care safer.