Five years after the publication of the landmark Institute of Medicine report
To Err Is Human, funded in part by The Commonwealth Fund, the U.S. health system still gets a C+ on patient safety, according to patient safety expert Robert Wachter, M.D.
(12) Some strides have been made, but many possible and desirable changes remain unimplemented. For example, one-third of Americans report they have directly experienced a medical error in the last two years—a rate in excess of those reported in industrialized nations such as Germany and the United Kingdom.
(13)However, some promising actions are being taken. The 100,000 Lives Campaign, spearheaded by the Institute for Healthcare Improvement, has engaged more than 2,900 hospitals in reducing preventable adverse events—such as acquiring ventilator-associated pneumonia—that can cost hospital patients their lives.
(14) The Joint Commission on Accreditation of Healthcare Organizations requires that hospitals have a policy of notifying patients of preventable adverse events, and some state health agencies require reporting medical errors. Insurers could reinforce these efforts by declining to pay for hospitalizations in which patients experience one of 27 well-defined "never events"—serious, largely preventable adverse events that should never happen in American hospitals, according to the National Quality Forum.
(15) In January 2005, HealthPartners of Minnesota began a policy of withholding payments to hospitals for such medical errors. The state of Minnesota, meanwhile, has enacted a law requiring hospitals to disclose when a "never event" occurs.
