Patient Safety

Defining the Problem

Patient safety and medical errors are closely linked, and in discussing one it is often necessary to discuss the other. For this entry, patient safety is defined as freedom from accidental injury due to medical care or medical errors. Medical error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, including problems in medical practice, products, procedures, and systems.

The term patient safety was first used in the name of a professional medical organization in 1984, with the establishment of the Anesthesia Patient Safety Foundation by the American Society of Anesthesiologists. Despite the recognition of patient safety issues in the field of anesthesia, the topic did not gain national attention until the late 1990s, solidified by the national Institute of Medicine (IOM) landmark report To Err Is Human: Building a Safer Health System, which was published in 2000. The report estimated that between 44,000 and 98,000 people die in the United States every year due to medical errors. It also estimated that the national cost of medical errors to hospitals was between $17 and $29 billion per year.

The IOM report cited commonly occurring errors, including adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. The report also cited an article in the Quality Review Bulletin (1993) that categorized medical errors broadly into diagnostic (e.g., error or delay in diagnosis, failure to employ tests, using outdated tests, and failure to act on results), treatment (error in performance or administration of treatment, avoidable delay in treatment, error in dose or method of using a drug, and inappropriate care), preventive (failure to provide prophylactic treatment and failure to monitor), or other (failure of communication and equipment failure) groups.

Following the IOM report, further studies were conducted to track medical errors and patient safety issues. A study published in the Journal of the American Medical Association in 2003 found that the greatest injury due to medical errors was postoperative sepsis leading to an excess length of hospital stay of 11 days, excess charges of $57,727, and excess mortality of 22%.

A HealthGrades Quality Study, which was published in 2004 and investigated hospitalized Medicare patients between 2000 and 2002, found more than 1 million adverse events resulting in up to 195,000 accidental deaths per year. Based on the Agency for Healthcare Research and Quality's (AHRQ's) 20 evidence-based patient safety indicators, the study found that the three most common errors were failure to rescue (failure to diagnose and treat in time), decubitus ulcer, and postoperative sepsis. These three errors accounted for almost 60% of all patient safety incidents among the hospitalized Medicare patients, with an estimated excess annual cost of $2.85 billion.

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