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

FIVE YEARS AFTER THE INSTITUTEof Medicine (IOM) reported thatas many as 98 000 people dieannually as the result of medi-cal errors and called for a national ef-fort to make health care safe, it is time to assess our progress. Is health care safer now? And, if not, why not? The IOM’s report, To Err Is Human: Building a Safer Health System,1 galva-nized a dramatically expanded level of conversation and concern about pa-tient injuries in health care both in the United States and abroad. Patient safety, a topic that had been little understood and even less discussed in care sys-tems, became a frequent focus for jour-nalists, health care leaders, and con-cerned citizens. Small but consequential changes have gradually spread through hospi-tals, due largely to concerted activities by hospital associations, professional societies, and accrediting bodies. All hospitals have implemented some new practices to improve safety. Fewer pa-tients die from accidental injection of concentrated potassium chloride, now that it has been removed from nursing unit shelves2; fewer patients have com-plications from warfarin, now that many taking anticoagulants are being treated in dedicated clinics3; and serious infec-tions have been reduced in hospitals that have tightened infection control procedures ( J. Whittington, writte