Fifteen Years After To Err is Human: A Success Story to Learn From

In late 1999, the Institute of Medicine released To Err is Human, a report that grabbed the world’s attention. It stated that up to 98,000 patients die each year in the United States from medical errors.  But little was done to reduce infections and other harms at that time.

In the article, Fifteen Years After To Err is Human, Dr. Peter J. Pronovost, Sr. Vice President for Patient Safety and Quality, Director of the Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine joined co-authors from HHS, CDC and ARHQ to highlight a key success story in protecting patients. Combined and coordinated efforts to reduce central line associated bloodstream infections (CLABSI) infections turned the tide in thinking that healthcare-associated infections were inevitable, instead showing clinicians and policymakers that these infections can be prevented by great numbers and patient mortality can be decreased.

The authors detail how a change in attitude, driven by five essential elements has led to national success in reducing CLABSI rates. These essential elements include:

• Reliable and valid measurement systems
• Evidence-based care practices
• Investment in implementation science
• Local ownership and peer learning communities
• Align and synergize efforts around common goals and measures

In 2009, a national five year CLABSI prevention goal was set at 50% following this approach. By 2013, infections were reduced by 46% in intensive care units.

For more on this success story and insights into the components which led to the dramatic reductions in CLABSI, please visit: BMJ Quality & Safety website.