by LT Kohn · Cited by 23659 — Distribution, posting, or copying of this PDF is strictly prohibited without written resulting from medical intervention related to a drug.55 Not all ADEs are.

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AUTHORSDETAILS Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press. (Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences. Copyright © National Academy of Sciences. All rights reserved. THE NATIONAL ACADEMIES PRESS Visit the National Academies Press at and login or register to get: Œ 10% off the price of print titles Œ Special offers and discounts BUY THIS BOOK FIND RELATED TITLES This PDF is available at SHARE Err Is Human: Building a Safer Health System312 pages | 6 x 9 | HARDBACKISBN 978-0-309-06837-6 | DOI 10.17226/9728Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee onQuality of Health Care in America, Institute of Medicine

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Building a Safer Health SystemLinda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, EditorsCommittee on Quality of Health Care in AmericaINSTITUTE OF MEDICINENATIONAL ACADEMY PRESS Washington, D.C. To Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the GoverningBoard of the National Research Council, whose members are drawn from the councils ofthe National Academy of Sciences, the National Academy of Engineering, and the Insti- tute of Medicine. The members of the committee responsible for the report were chosenfor their special competences and with regard for appropriate balance.Support for this project was provided by The National Research Council and TheCommonwealth Fund. The views presented in this report are those of the Institute ofMedicine Committee on the Quality of Health Care in America and are not necessarilythose of the funding agencies.Library of Congress Cataloging-in-Publication DataTo err is human : building a safer health system / Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Includes bibliographical references and index.ISBN 0-309-06837-1 1. Medical errorsÑPrevention. I. Kohn, Linda T. II. Corrigan, Janet. III. Donaldson, Molla S.R729.8.T6 2000 362.1Ñdc2199-088993 Additional copies of this report are available for sale from the National Academy Press,2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055; call (800) 624-6242 or (202) 334-3313 in the Washington metropolitan area, or visit the NAP on-line book- store at .The full text of this report is available on line at For more information about the Institute of Medicine, visit the IOM home page Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of AmericaThe serpent has been a symbol of long life, healing, and knowledge among almostall cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.To Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to thefurtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man-date that requires it to advise the federal government on scientific and technical matters.Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers.It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government.The National Academy of Engineering also sponsors engineering programs aimed atmeeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering.The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressionalcharter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with theAcademyÕs purposes of furthering knowledge and advising the federal government. Func- tioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences andthe National Academy of Engineering in providing services to the government, the pub-lic, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council. National Academy of SciencesNational Academy of Engineering Institute of Medicine National Research Council To Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. KelloggFoundation, Battle Creek, MIDONALD M. BERWICK, President and CEO, Institute for HealthcareImprovement, BostonJ. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta LONNIE R. BRISTOW, Past President, American Medical Association,Walnut Creek, CACHARLES R. BUCK, Program Leader, Health Care Quality and StrategyInitiatives, General Electric Company, Fairfield, CTCHRISTINE K. CASSEL, Professor and Chairman, Department ofGeriatrics and Adult Development, Mount Sinai School of Medicine, New York CityMARK R. CHASSIN, Professor and Chairman, Department of Health Policy,Mount Sinai School of Medicine, New York CityMOLLY JOEL COYE, Senior Vice President and Director, West CoastOffice, The Lewin Group, San FranciscoDON E. DETMER, Dennis Gillings Professor of Health Management,University of Cambridge, UKJEROME H. GROSSMAN, Chairman and CEO, Lion Gate ManagementCorporation, BostonBRENT JAMES, Executive Director, Intermountain Health Care, Institutefor Health Care Delivery Research, Salt Lake City, UTDAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation HealthPlan, Inc., Oakland, CALUCIAN LEAPE, Adjunct Professor, Harvard School of Public Health ARTHUR LEVIN, Director, Center for Medical Consumers, New York City RHONDA ROBINSON-BEALE, Executive Medical Director, ManagedCare Management and Clinical Programs, Blue Cross Blue Shield of Michigan, SouthfieldJOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University ofCalifornia at Irvine College of MedicineARTHUR SOUTHAM, Partner, 2C Solutions, Northridge, CA MARY WAKEFIELD, Director, Center for Health Policy and Ethics,George Mason UniversityGAIL L. WARDEN, President and CEO, Henry Ford Health System,DetroitvTo Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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viiReviewersThis report has been reviewed in draft form by individuals chosen fortheir diverse perspectives and technical expertise, in accordance withprocedures approved by the National Research Council Õs Report Re-view Committee. The purpose of this independent review is to provide can-did and critical comments that will assist the Institute of Medicine in mak-ing the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remainconfidential to protect the integrity of the deliberative process. The commit- tee wishes to thank the following individuals for their participation in thereview of this report:GERALDINE BEDNASH, Executive Director, American Association ofColleges of Nursing, Washington, DCPETER BOUXSEIN, Visiting Scholar, Institute of Medicine, Washington,DCJOHN COLMERS, Executive Director, Maryland Health Care Cost andAccess Commission, BaltimoreJEFFREY COOPER, Director, Partners Biomedical Engineering Group,Massachusetts General Hospital, BostonROBERT HELMREICH, Professor, University of Texas at AustinTo Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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viiiREVIEWERSLOIS KERCHER, Vice President for Nursing, Sentara-Virginia BeachGeneral Hospital, Virginia Beach, VAGORDON MOORE, Associate Chief Medical Officer, Strong Health, Rochester, NY ALAN NELSON, Associate Executive Vice President, American College ofPhysicians/American Society of Internal Medicine, Washington, DCLEE NEWCOMER, Chief Medical Officer, United HealthCare Corporation,Minnetonka, MNMARY JANE OSBORN, University of Connecticut Health Center ELLISON PIERCE, Executive Director, Anesthesia Patient SafetyFoundation, BostonAlthough the individuals acknowledged have provided valuable com-ments and suggestions, responsibility for the final contents of the reportrests solely with the authoring committee and the Institute of Medicine.To Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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To Err Is Human: Building a Safer Health System. The title of thisreport encapsulates its purpose. Human beings, in all lines of work,make errors. Errors can be prevented by designing systems that makeit hard for people to do the wrong thing and easy for people to do the rightthing. Cars are designed so that drivers cannot start them while in reverse because that prevents accidents. Work schedules for pilots are designed so they donÕt fly too many consecutive hours without rest because alertness and performance are compromised.In health care, building a safer system means designing processes of careto ensure that patients are safe from accidental injury. When agreement has been reached to pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the bestchance possible of achieving the desired outcome.This report describes a serious concern in health care that, if discussedat all, is discussed only behind closed doors. As health care and the systemthat delivers it become more complex, the opportunities for errors abound.Correcting this will require a concerted effort by the professions, health care organizations, purchasers, consumers, regulators and policy-makers. Tradi- tional clinical boundaries and a culture of blame must be broken down. Butmost importantly, we must systematically design safety into processes of care. This report is part of larger project examining the quality of health carePrefaceixTo Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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xPREFACEin America and how to achieve a threshold change in quality. The committee has focused its initial attention on quality concerns that fall into the categoryof medical errors. There are several reasons for this. First, errors are respon-sible for an immense burden of patient injury, suffering and death. Second, errors in the provision of health services, whether they result in injury orexpose the patient to the risk of injury, are events that everyone agrees just shouldnÕt happen. Third, errors are readily understandable to the Americanpublic. Fourth, there is a sizable body of knowledge and very successfulexperiences in other industries to draw upon in tackling the safety problemsof the health care industry. Fifth, the health care delivery system is rapidly evolving and undergoing substantial redesign, which may introduce im-provements, but also new hazards. Over the next year, the committee will be examining other quality issues, such as problems of overuse and underuse.The Quality of Health Care in America project is largely supported withincome from an endowment established within the IOM by the HowardHughes Medical Institute and income from an endowment established for the National Research Council by the Kellogg Foundation. The Common-wealth Fund provided generous support for a workshop to convene medi-cal, nursing and pharmacy professionals for input into this specific report. The National Academy for State Health Policy assisted by convening a focusgroup of state legislative and regulatory leaders to discuss patient safety. Thirty-eight people were involved in producing this report. The Sub-committee on Creating an External Environment for Quality, under the di- rection of J. Cris Bisgard and Molly Joel Coye, dealt with a series of complex and sensitive issues, always maintaining a spirit of compromise and respect.Additionally the Subcommittee on Designing the Health System of the 21stCentury, under the direction of Donald Berwick, had to balance the chal- lenges faced by health care organizations with the need to continually pushout boundaries and not accept limitations. Lastly, under the direction of Janet Corrigan, excellent staff support has been provided by Linda Kohn, Molla Donaldson, Tracy McKay, and Kelly Pike. At some point in our lives, each of us will probably be a patient in thehealth care system. It is hoped that this report can serve as a call to action that will illuminate a problem to which we are all vulnerable.William C. Richardson, Ph.D. ChairNovember 1999To Err Is Human: Building a Safer Health SystemCopyright National Academy of Sciences. All rights reserved.

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