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Special Communication
May 18, 2005

Five Years After To Err Is Human : What Have We Learned?

Author Affiliations

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.

JAMA. 2005;293(19):2384-2390. doi:10.1001/jama.293.19.2384

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.