Medical Mistakes Are 'Leading Cause' of Death and Disability
Examples of systems errors include the classic, poor handwriting on paper prescriptions. If physicians in a health care system type prescriptions onto an electronic template, the risk of penmanship-related problems is eliminated. While individual physicians and pharmacists have little recourse other than being more careful about drugs with similar names, the FDA can monitor these names and call attention to the possibility of confusing them, Kohn tells WebMD.
Another example she cites is the rapid growth in medical knowledge, which makes keeping abreast difficult for health care workers. "Access to information, at the right place and at the right time, can help improve safety," she says.
Mainstream media analyses have been skeptical about organized medicine's concern about patient safety, which they view as belated. For example, in the New York Times, Lawrence K. Altman questions "why, after so many years of public attention to medical malpractice, the National Academy of Sciences wants to crack down now."
Systemically based errors can be reduced without making health care professionals even more vulnerable to lawsuits, and without reinventing the wheel, Wade tells WebMD. "[O]ur systems for preventing [errors] are not what the public would expect of us," he says. "We need a reporting mechanism that will [allow information to be used] for all the right reasons and not used for all the wrong reasons. ... We can improve our systems by finding the places where medical error prevention is being done well and translating that information across the system. This approach will help us develop a system of safeguards that improve patient safety."
The IOM report is the first in a series to be issued by the Quality of Health Care in America Project, says Kohn. In a statement issued by the National Patient Safety Foundation (NPSF), which was founded by the American Medical Association, Nancy W. Dickey, MD, calls for continued vigilance against errors, and says, "While we may never achieve perfection, we must strive for it." She is past president of the AMA and past chairwoman of NPSF's board of directors.
The IOM is a private, nonprofit institution.