For more than 2 decades, since the release of the Institute of Medicine’s groundbreaking report To Err is Human: Building a Safer Health System¸ hospitals and health care systems have struggled to understand and improve patient safety. On the basis of 2 large epidemiologic studies, the Institute of Medicine estimated in 1999 that 44 000 to 98 000 patients were being killed each year in the US due to medical errors and called for this rate to be halved within 5 years. The federal government and health systems responded to this call with an increased investment of funding and personnel committed to getting the patient safety epidemic under control. While our collective understanding of the human and systemic drivers of medical errors grew, it became painfully clear that the ambitious goal of halving harms within 5 years was not being achieved. Despite the initiation of patient safety improvement efforts across the country, 10 years after To Err in Human, the US Office of the Inspector General estimated that 180 000 patients were dying each year due to adverse events in hospitals. The North Carolina Patient Safety study found no improvement in rates of patient harms over a 6-year span. In 2016, Makary and Daniel estimated that the true rate of harm due to medical errors could be 251 000 deaths per year or more, a rate that, if accurate, would have made medical error the third leading cause of death in the US then and the fourth leading cause now in the COVID-19 era. While evolving definitions and methodologies over time—as well as the (continued) absence of a robust adverse event surveillance system in the US—make it unclear if patient safety was truly getting worse, little evidence existed to suggest it was getting any better. Certainly, we had accomplished nothing like the Institute of Medicine’s goal of halving medical errors even in the first 15 years of the patient safety movement, never mind the originally hoped for 5 years.
Clinical Practice Guidelines