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the only way to improve quality15). The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

Health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety. Aviation has focused extensively on building safe systems and has been doing so since World War II. Between 1990 and 1994, the U.S. airline fatality rate was less than one-third the rate experienced in mid century.16 In 1998, there were no deaths in the United States in commercial aviation. In health care, preventable injuries from care have been estimated to affect between three to four percent of hospital patients.17 Although health care may never achieve aviation's impressive record, there is clearly room for improvement.

To err is human, but errors can be prevented. Safety is a critical first step in improving quality of care. The Harvard Medical Practice Study, a seminal research study on this issue, was published almost ten years ago; other studies have corroborated its findings. Yet few tangible actions to improve patient safety can be found. Must we wait another decade to be safe in our health system?

Recommendations

The IOM Quality of Health Care in America Committee was formed in June 1998 to develop a strategy that will result in a threshold improvement in quality over the next ten years. This report addresses issues related to patient safety, a subset of overall quality-related concerns, and lays out a national agenda for reducing errors in health care and improving patient safety. Although it is a national agenda, many activities are aimed at prompting responses at the state and local levels and within health care organizations and professional groups.

The committee believes that although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Whether a person is sick or just trying to stay healthy, they should not have to worry about being harmed by the health system itself. This report is a call to action to make health care safer for patients.

The committee believes that a major force for improving patient safety

Front Matter (R1-R24)

Executive Summary (1-16)

1 A Comprehensive Approach to Improving Patient Safety (17-25)

2 Errors in Health Care: A Leading Cause of Death and Injury (26-48)

3 Why Do Errors Happen? (49-68)

4 Building Leadership and Knowledge for Patient Safety (69-85)

5 Error Reporting Systems (86-108)

6 Protecting Voluntary Reporting Systems from Legal Discovery (109-131)

7 Setting Performance Standards and Expectations for Patient Safety (132-154)

8 Creating Safety Systems in Health Care Organizations (155-204)

A Background and Methodology (205-209)

B Glossary and Acronyms (210-214)

C Literature Summary (215-253)

D Characteristics of State Adverse Event Reporting Systems (254-265)

E Safety Activities in Health Care Organizations (266-272)

Index (273-287)