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To Err Is Human (report)

To Err Is Human (report) is a science topic covered in the lgStudy science library. This page brings together a partial reference excerpt, illustrations, worked examples, real-world applications and a short study plan, so you can understand To Err Is Human (report) rather than just read about it. In short: To Err Is Human: Building a Safer Health System is a landmark report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors.

Key takeaways

  • To Err Is Human (report) belongs to science; place it in that map before memorising details.
  • Learn the definition first, then one example that makes the definition concrete.
  • Connect To Err Is Human (report) to a quantity you can measure, compute or draw — that is where exam questions come from.
  • Reproduce the core statement of To Err Is Human (report) from memory before moving on to harder problems.

Reference excerpt

To Err Is Human: Building a Safer Health System is a landmark report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors. The push for patient safety that followed its release continues. The report was based upon analysis of multiple studies by a variety of organizations and concluded that between 44,000 and 98,000 people die each year as a result of preventable medical errors. For comparison, fewer than 50,000 people died of Alzheimer's disease and 17,000 died of illicit drug use in the same year. The report called for a comprehensive effort by health care providers, government, consumers, and others. Claiming knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next five years. Though not currently quantified, as of 2007 this ambitious goal has yet to be met.

Impact The report "brought the issues of medical error and patient safety to the forefront of national concern". The report has been called "groundbreaking" for suggesting that 2–4% of all deaths in the United States are caused by medical errors. The report is credited with raising awareness of the extent to which medical error was a problem. The report described that errors were not rare or isolated, and only by broad planning could they be diminished. It also described that most errors are systemic in the health care industry, and cannot be resolved at the level of individual health care providers.

Responses The report had a huge impact on management of health care. As a result of the report President Bill Clinton signed Senate bill 580, the Healthcare Research and Quality Act of 1999, which renamed the Agency for Health Care Policy and Research to Agency for Healthcare Research and Quality to indicate a change in focus. The bill also funded projects through that organization.

Follow up The report was followed in 2001 by another widely cited Institute of Medicine report, "Crossing the Quality Chasm," which furthers many points from the original study. Both are widely referenced. "To Err Is Human" was the inspiration for the Institute for Healthcare Improvement's 100,000 Lives Campaign [1], which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals.

See also Diagnosis Medical ethics How Doctors Think Fatal Care: Survive in the U.S. Health System

References

External links On-line access to Institute of Medicine publication "To Err Is Human, Building a Safety Health System" (2000).

Worked examples

Example 1 — a first encounter with To Err Is Human (report)

Start with the simplest possible case. Write down what To Err Is Human (report) claims or describes in one sentence, then invent the smallest concrete situation in which that sentence is true. In science, the smallest case is usually a single object, a single equation or a single measurement. Check that every symbol or term in your sentence has a meaning in that case.

Example 2 — changing one variable

Take the situation from Example 1 and change exactly one quantity: double it, halve it, or set it to zero. Predict what should happen to To Err Is Human (report) before you calculate. Comparing your prediction with the result is the fastest way to find out whether you understand the idea or only the words.

Example 3 — an exam-style question

Typical questions about To Err Is Human (report) ask you to (a) state it precisely, (b) apply it to given data, and (c) explain a limitation. Practise writing all three answers in under five minutes; the third part is what separates a full-mark answer from an average one.

Applications of To Err Is Human (report)

In research
To Err Is Human (report) appears in science research whenever the underlying quantities have to be modelled precisely. Papers usually cite it as a starting assumption and then explore where it breaks down.
In technology and industry
Engineering practice reuses To Err Is Human (report) in design rules, simulations and safety margins. Knowing the idea lets you read a specification sheet and understand why the numbers look the way they do.
In the classroom
To Err Is Human (report) is common in secondary-school and first-year university syllabi. It links to neighbouring topics 1999 documents, Medical literature, Nursing, so understanding it makes those chapters shorter.
In everyday life
Look for To Err Is Human (report) outside the textbook — in sport, cooking, traffic, electronics or the sky above you. An example you found yourself is remembered far longer than one you were given.
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How to study To Err Is Human (report) in 20 minutes

  1. Read the reference excerpt below once, without taking notes.
  2. Close the page and write down what To Err Is Human (report) means in your own words.
  3. Compare your version with the excerpt and mark what you missed.
  4. Work through the three examples above with pen and paper.
  5. Explain To Err Is Human (report) out loud to somebody else — or to Teacher Smith in the lgStudy chat.

Frequently asked questions

What is To Err Is Human (report) in simple terms?

To Err Is Human: Building a Safer Health System is a landmark report issued in November 1999 by the U.S. Institute of Medicine that may have resulted in increased awareness of U.S. medical errors.

Why does To Err Is Human (report) matter?

Because it connects several science ideas at once: it gives you a definition you can apply, a quantity you can calculate, and a way to check whether a result is plausible.

How should I study To Err Is Human (report)?

Read the excerpt, restate it from memory, then work through the examples and applications listed on this page. The five-step study plan above takes about twenty minutes.

What does this page cover?

It gives you a compact reference excerpt plus original lgStudy explanations, examples, applications and study material on To Err Is Human (report).

Tags

  • 1999 documents
  • Medical literature
  • Nursing
  • Patient safety

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