Summary Of To Err Is Human

The grey group started our discussion with the major points from To Err is Human. The main point of To Err is Human is that most medical errors are not caused by incompetence but are instead caused by a faulty medical system (Palatnik, 2016). The report drew attention to the growing problem of medical errors to society and sparked a transformation within healthcare systems to improve patient safety and outcomes. Throughout the discussion multiple organizations surfaced as a result of the report such as the Agency for Healthcare Research and Quality. Outside of organization, the passage of the Patient Safety and Quality Improvement Act (PSQIA) which created a federal medical error reporting system (Clancy, 2009). Aspects such as error reporting

Crossing the Quality Chasm, focused on the deficiencies in health care quality in the U.S., analyzed contributing factors, and proposed recommendations for improvement. While To Err is Human focused mainly on patient safety, Crossing the Quality Chasm, proposed changes to the healthcare system so that care in the 21st century will be evidence-based, patient-centered, cost-effective, transparent and will utilize all of the available technologies in a safe and effective manner. We discussed the six aims to improve healthcare the report proposed which are: safe, effective, patient-centered, timely, efficient and equitable. The thought was that if healthcare used the six aims and excelled in these areas, patient needs would be met or exceeded (Institute of Medicine (US) Committee on Quality of Health Care in America (2001). The thirteen recommendations from the Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998), whose goal was to improve healthcare in the U.S. were adopted by the committee on Quality of Health Care in America, was discussed a

The 100,000 Lives Campaign included six best practices used to save lives. One of the best practices we discussed in our particular discussion was the use of rapid response teams. The goal of rapid response teams is to “identify patients at risk for rapid decline in condition and intervene prior to a catastrophic event such as cardiopulmonary arrest” (Solomon, Corwin, Barclay, Quddusi & Dannenberg, 2016) . As a group we also discussed the 5 million lives campaign, whose goal was to dramatically reduce the levels of morbidity and mortality by supporting the improvement of medical care (Institute for Healthcare Improvement, n.d.). Error reporting systems and the impact it has on healthcare and patient safety were discussed as well as the advantages and disadvantages. Cohen (2000) says that while the intent of mandatory systems is to establish a baseline level of patient safety, in practice, these systems are used to punish and remove certain providers from practices, placing the focus on the individual rather than the error and how it could have been prevented, and that in order to truly be open and honest and improve patient safety, practitioners need “freedom from punishment” (Cohen, 2000, p.