Critique of “To Err is Human”

Christina Claar

SNU 471 45: Quality Health Care Delivery

Dr. Carrie Slagle

March 26, 2022

 The Institute of Medicine was founded in 1970 with a mission to “improve health for all

by advancing science, accelerating health equity, and providing independent, authoritative, and

trusted advice nationally and globally” (National Academy of Medicine, 2022). Now called the

National Academy of Medicine, they act as an independent, evidence-based scientific advisor

with a goal of being the most reliable source for credible information on matters concerning

health. The academy includes members from across the globe and partners with the National

Academy of Sciences and the National Academy of Engineering to work toward advancing

science, medicine, technology, and health.

The Institute of Medicine published To Err is Human: Building a Safer Health System in

2000 and exposed the deadly mistakes that were happening every year in the United States

health care system. This report defined medical errors as “the failure of a planned action to be

completed as intended or the use of a wrong plan to achieve an aim (Institute of Medicine,

1999). The report brief also stated that preventable medical errors in hospitals exceed deaths

from car accidents, breast cancer, and AIDS (1999). Combined with the financial cost that also

comes with this amount of errors, the nation became aware that this was a very serious

problem that should be addressed as soon as possible, and legislation and policies were soon

put in place to take action.

The IOM report identified areas that seemed to be the weaknesses of the health care

system that allowed errors to occur. One point of importance was the lack of a centralized

system; as patients saw care from multiple providers, coordination of care required more effort

and information was not easily transferrable and accessible. This was only a part of the much

larger problem as it is only one element of the entire system. According to the IOM,
“preventing errors and improving safety for patients require a system approach in order to

modify the conditions that contribute to errors” (IOM, 2000). Health care professions require

more education and training than most other careers, so the people in those roles are

intelligent and capable, but they still need a system that is designed for safety. After all, latent

errors pose a greater threat to safety in a complex system because they are more often

unrecognized and could potentially result in multiple active errors (IOM, 2000). Thus, the IOM

recommended that errors be investigated at the system level rather than focusing on the

individual who committed said error – a system functioning properly should not have allowed it

to happen in the first place.

Perhaps the most surprising conclusion of the research of this report was the impact of

human error on health care and patient safety and how it has changed as technology has

grown. As stated in the IOM report, “technology changes the tasks that people do by shifting

the workload and eliminating human decision making” (IOM, 2000). The previous method of

rectifying errors was to find the person responsible and focus on preventing them from doing it

again, maybe through additional training or punishment for negligence. As technology has

changed processes, that is not always an option anymore as more processes have become

more complex and increasingly automated. When this is the case, errors are much more

difficult to identify and fix; even though technology comes with so many benefits, there are

going to be a few drawbacks.

Following the research, data collection, and preparation of the report, the Institute of

Medicine recommended a four-tiered approach for health care safety to improve. This

consisted of 1) establishing a national focus to create leadership, research, tools, and protocols
to enhance the knowledge base about safety, 2) identifying and learning from errors by

developing a nationwide public mandatory reporting system and encouraging health care

systems to participate in voluntary reporting, 3) raising performance standards and

expectations for improvements in safety, and 4) implementing safety systems in health care

organizations to ensure safe practices at the delivery level (Institute of Medicine, 1999). This

work proved to be not for naught as initiatives and programs began development at the

government level and in private sectors almost immediately.

In response to the IOM report, the United States government agencies that oversaw

health care programs were instructed to implement proven techniques for reducing medical

errors as well as create task forces to find new strategies. Congress allotted $50 million to the

Agency for Healthcare Research and Quality to support their efforts at finding strategies as well,

and they have continued that work over the past two decades. Today, the AHRQ works to

produce evidence to "make healthcare safer, higher quality, more accessible, equitable, and

affordable" in the United States (AHRQ, 2022). The AHRQ developed patient safety indicators,

which collect data that can be used to identify safety problem areas, and they are continuously

working with hospitals to develop strategies to curb errors. It is through their work that the U.S.

health care system has prevented over a million medical errors and saved 50,000 lives.

Additionally, the National Academy for State Health Policy gathered state leadership to discuss

methods of improving patient safety, and they helped to lead an initiative to better understand

how states administer and enforce their mandatory hospital error-reporting requirements

(IOM, 1999).
 The Institute of Medicine did a great service to the world in providing this report,

collecting all of the necessary data, and advising health care systems on how to improve for the

benefit of patients, quality, and safety. Health care organizations have since dedicated more of

their resources to understanding systems and paying more attention to correcting them when

errors occur. Error reporting has increased, and safety standards help to ensure that safety is

considered a priority in all health care settings. Technology has certainly contributed to a

decline in medical errors, and one area in particular that was mentioned previously has had

notable changes. Electronic health records now allow for a more streamlined coordination of

care, and government initiatives have helped make them the standard. To err is indeed human,

but even more so is to learn.

 References

Agency for Healthcare Research and Quality. (2022). Mission & Budget. AHRQ. Retrieved March

26, 2022, from https://www.ahrq.gov/cpi/about/mission/index.html

Institute of Medicine (1999). To err is human: Building a safer healthcare system: Report Brief,

p.1-8.

Institute of Medicine (2000). To Err is Human: Building a Safer Health System. National

Academies Press (US).

National Academy of Medicine. (2022, February 28). About the NAM. National Academy of

Medicine. Retrieved March 26, 2022, from https://nam.edu/about-the-nam/