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Patient Safety Still Problematic 20 Years After 'To Err Is Human' Report

Analysis  |  By Christopher Cheney  
   November 27, 2019

There have been leaps forward in patient safety over the past 20 years but harm remains far too common, two experts say.

Progress has been made in patient safety improvements but many more advances are needed, a pair of experts say regarding the 20-year anniversary of the landmark report To Err Is Human: Building a Safer Health System.

The 1999 report included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Yet despite two decades of attention, estimates of annual patient deaths due to medical errors have since risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

HealthLeaders recently spoke with two experts to discuss how far healthcare has come since the release of To Err Is Human, and what progress still needs to be made regarding patient safety.  

Eric Eskioglu, MD, is executive vice president and CMO of Winston-Salem, North Carolina-based Novant Health, a practicing neurosurgeon, and a former aerospace engineer at Chicago-based Boeing.

Anne Marie Benedicto, MPP, MPH, is vice president of the Center for Transforming Healthcare at The Joint Commission, based in Oakbrook, Illinois. The Center for Transforming Healthcare was formed in 2009 to help healthcare organizations achieve zero harm in patient care.

The following is a lightly edited transcript of the conversations with Eskioglu and Benedicto.

HealthLeaders: Gauge the progress in patient safety since the publication of To Err Is Human.

Eskioglu: There have been advances, but they are not enough. In my view, we have advanced, but we have not advanced at the rapid clip required. I came from the aerospace industry, where there was a huge advance in safety from 1989 to now. That's why we have done really well in airline safety and reducing deaths in airline crashes. We have not come far enough in healthcare.

Benedicto: There has been some progress, most strikingly in the declines of healthcare-acquired infections such as central line-associated bloodstream infections. However, from the perspective of 20 years, there is some disappointment. People are still being harmed in the course of receiving or giving care. There are practices in healthcare that fail routinely; for example, hand hygiene is only being done 50% of the time. Wrong-side surgery is an example of an extreme adverse event that never should happen but does happen. So, we are still seeing routine common harm as well as adverse dramatic harm 20 years after To Err Is Human.

HL: Give an example of a major leap forward since the publication of To Err Is Human.

Eskioglu: One of the biggest advances we have made is the process of double checking such as the surgical checklist developed by Martin Makary at Johns Hopkins. That was a big advancement in the operating room field. Before that, we didn't have a surgical pre-op checklist. What we ended up having were many wrong-sided surgeries, wrong implants, even wrong patients operated on because once you put the patient under anesthesia, they don't know what is going to happen to them.

HL: Pick one or two areas related to patient safety that are on your wish list for improvement.

Benedicto: I would give healthcare organizations enormous improvement capabilities and capacity. They would have a workforce that is familiar with improvement methods and use them in their daily work, so they would be constantly improving. One of the biggest gaps in achieving zero harm is there are so many things that could be improved in healthcare organizations and there is a lack of improvement skills. At hospitals, which are complicated organizations that often have thousands of employees, there may only be 30 people who are trained in improvement skills. That is not enough to solve all of the problems and challenges that healthcare organizations encounter every day.

Eskioglu: I would stop all the preventable deaths from falls, missed diagnoses, and delayed treatment, as well as remove burdens from the physicians so they could concentrate on what they do best—taking care of patients—rather than being data entry clerks. We need to help physicians with artificial intelligence and analytics. Artificial intelligence is not going to tell doctors what to do, but it will be like flying a plane; if a pilot mistakenly does something wrong, an alert system comes on and says, "Are you sure you want to do this?" We don't have that in medicine.

HL: Give an example of a remaining major obstacle to improving patient safety.

Eskioglu: One area where we are lagging is data. Each patient's data is like a Woolly Mammoth locked up in a glacier. It's waiting to be unfrozen and used to the betterment of the patient. The next time you go to your primary care physician, ask, "How far do you go back in my records before you see me? Is it one note? Two notes?" If you have been with the same physician for 15 years, you probably have accumulated at least 30 notes. Does your physician go through all 30 notes and look for patterns? I can tell you that does not happen.

Benedicto: We need to aim higher—not just aim for better—and go for zero harm. We need to make healthcare as safe as established high-reliability organizations such as commercial airlines or the nuclear power industry. Even though they operate in high-hazard environments, they have the systems and structures to achieve exemplary safety records. Healthcare is not there yet, but we can achieve high reliability. Leadership commitment to zero harm is the first step. Working on culture also is important because high-reliability organizations have strong safety cultures. We also need strong improvement capacity and capabilities.

HL: What would zero harm in healthcare look like?

Eskioglu: It would be multiple, relentless, obsessive checks and balances just like the aerospace industry did. It doesn't mean that you are never going to have another preventable death over the next 10 years in any hospital. But it is going to be so rare that that one unfortunate incident is going to make us look at the root cause and not repeat that mistake again. To me, that is relentless pursuit of safety and doing no harm.

Benedicto: The obvious answer is we would see harm go away. Patients would not fall. People would not get injured. There would be no pressure ulcers. There would be no healthcare-acquired infections. But the benefits of zero harm go beyond the clinical areas. The focus on consistent excellence that creates the ability to reach zero harm means that you would have an organization that is focused on consistent excellence in all areas. Your billing department would be strong. You would be strong operationally. Your supply chain would be strong. Many factors influence zero harm, clinical outcomes, and patient care.

Christopher Cheney is the CMO editor at HealthLeaders.


In 1999, the landmark report To Err Is Human estimated that as many as 98,000 patients died annually from medical errors.

Despite publication of To Err Is Human, estimates of deaths from medical errors have increased. In 2013, an article published in the Journal of Patient Safety estimated annual patient deaths from medical errors were as high as 440,000.

High reliability in the commercial aviation industry provides guideposts for the healthcare industry to follow to achieve zero harm.

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