Patient safety

Patient safety is a discipline and responsibility that emphasizes safety in health care through the prevention, reduction, reporting, and analysis of medical error that often leads to adverse effects. The frequency and magnitude of avoidable adverse events experienced by patients was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety. At the same time, efforts are being made to anchor patient safety more firmly in medical education. The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers and consumers, enhancing error reporting systems, and developing new economic incentives. Patient safety is a discipline and responsibility that emphasizes safety in health care through the prevention, reduction, reporting, and analysis of medical error that often leads to adverse effects. The frequency and magnitude of avoidable adverse events experienced by patients was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety. At the same time, efforts are being made to anchor patient safety more firmly in medical education. The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers and consumers, enhancing error reporting systems, and developing new economic incentives. Millennia ago, Hippocrates recognized the potential for injuries that arise from the well-intentioned actions of healers. Greek healers in the 4th century BC drafted the Hippocratic Oath and pledged to 'prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.' Since then, the directive primum non nocere (“first do no harm) has become a central tenet for contemporary medicine. However, despite an increasing emphasis on the scientific basis of medical practice in Europe and the United States in the late 19th Century, data on adverse outcomes were hard to come by and the various studies commissioned collected mostly anecdotal events. In the United States, the public and the medical specialty of anesthesia were shocked in April 1982 by the ABC television program 20/20 entitled The Deep Sleep. Presenting accounts of anesthetic accidents, the producers stated that, every year, 6,000 Americans die or suffer brain damage related to these mishaps. In 1983, the British Royal Society of Medicine and the Harvard Medical School jointly sponsored a symposium on anesthesia deaths and injuries, resulting in an agreement to share statistics and to conduct studies. By 1984 the American Society of Anesthesiologists (ASA) had established the Anesthesia Patient Safety Foundation (APSF). The APSF marked the first use of the term 'patient safety' in the name of professional reviewing organization. Although anesthesiologists comprise only about 5% of physicians in the United States, anesthesiology became the leading medical specialty addressing issues of patient safety. Likewise in Australia, the Australian Patient Safety Foundation was founded in 1989 for anesthesia error monitoring. Both organizations were soon expanded as the magnitude of the medical error crisis became known. In the United States, the full magnitude and impact of errors in health care was not appreciated until the 1990s, when several reports brought attention to this issue.In 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released a report, To Err is Human: Building a Safer Health System. The IOM called for a broad national effort to include establishment of a Center for Patient Safety, expanded reporting of adverse events, development of safety programs in health care organizations, and attention by regulators, health care purchasers, and professional societies. The majority of media attention, however, focused on the staggering statistics: from 44,000 to 98,000 preventable deaths annually due to medical error in hospitals, 7,000 preventable deaths related to medication errors alone. Within 2 weeks of the report's release, Congress began hearings and President Clinton ordered a government-wide study of the feasibility of implementing the report's recommendations.Initial criticisms of the methodology in the IOM estimates focused on the statistical methods of amplifying low numbers of incidents in the pilot studies to the general population. However, subsequent reports emphasized the striking prevalence and consequences of medical error. The experience has been similar in other countries.