First organization developed expressly to improve safety for patients. - Anesthesia
Patient Safety Foundation - founded 1985.
Ellison Pierce - Established the Committee on Patient Safety and Risk Management in
1982; coined the term "patient safety", founded the Anesthesia Patient Safety
Foundation in 1985; delivered the Rovenstine Lecture in 1996.
1996's Rovenstine Lecture (40 Years behind the Mask: Safety Revisited) - Ellison
Pierce described the beginning of anesthesiology's patient safety movement
1982 20/20's The Deep Sleep: 6000 will Die or Suffer Brain Damage - Inspired Pierce's
Rovenstine Lecture about patient safety
After attending a workshop by Deming, Berwick realized he was misguided because he
had been - An inspector rather than a promoter of quality.
1988 Institute for Healthcare Improvement was founded by - Don Berwick, Paul
Batalden, and Gene Nelson. The institute focuses on all aspects of quality, but their
discovery of a modern approach to quality helped transform the patient safety
movement.
Harvard Medical Practice Study I and II - Published in 1991 by the New England Journal
of Medicine it had the results from two large studies of adverse medical events and
provided the evidence that significant numbers of patients are harmed by medical
treatment and a framework for understanding the types of harm they experience.
Harvard Medical Practice Study I - 30,000 Medical records from 1984 non psych
hospitals in NYS were screened for adverse events (injury caused by medical
management rather than underlying disease and prolonged the hospitalization or
produced a disability at the time of discharge) and negligence (care falling below the
standard expected of physicians in their community).
Harvard Medical Practice Study II - Classified the injuries described in Study I and the
management errors that were responsible.
Results of Harvard Medical Study II - Adverse events occurred in 3.7% of
hospitalizations and 27.6% of the events were due to negligence. 70.5% gave rise to
disability lasting less than six months, 2.6% caused permanently disabling injuries and
13.6% led to death. Unfortunately it did not lead to immediate change.
, Lucian Leape - Co-author of the Harvard Medical Practice Study; prominent leader in
the patient safety movement; discovered how cognitive psychology and human factors
engineering were important aspects of improving patient safety
1994's Error in Medicine published in the Journal of the American Medical Association -
Written by Lucian Leape it presented statistical evidence of the occurrence of harm
caused by medical errors along with lessons from other high risk industries such as
aviation.
The first mainstream article in healthcare literature arguing for a systems approach to
safety. - Error in Medicine by Lucian Leape.
In Error in Medicine, Leape identified 3 categories of medical errors - Medication errors,
missed diagnoses, operational errors such as delayed treatment.
In Error in Medicine, Leape states the most fundamental change that must be made is -
Cultural. Errors must be accepted as evidence of system flaws not character flaws.
Betsy Lehman 1994 Death - Occurred due to a medication error at Dana-Farber Cancer
Institute. Published in the Boston Globe and caused many to take Leape's Error in
Medicine more seriously.
Annenberg Conferences of 1996 and 1997 - Developed an interdisciplinary community
of people including patients and professionals from outside health care aimed at solving
patient safety problems.
Examining Errors in Health Care: Developing a Prevention, Education, and Research
Agenda - 1996 Annenberg Conference
A Tale of Two Stories: Contrasting Views of Patient Safety - 2nd Annenberg Conference
1997
1997's National Patient Safety Foundation - Established by the American Medical
Association at the Annenberg Conference to be a catalyst for action and a vehicle to
support change and track improvements in patient safety.
1998 National Academy of Sciences Institute of Medicine (IOM) - Charged the
Committee on Quality of Care in America with developing a strategy that will result in a
threshold improvement in quality over the next ten years.
1999 To Err is Human: Building a Safer Health System - First report issued by the IOM's
Committee on Quality of Care in America is considered to have launched the current
patient safety movement
To Error is Human found out this about adverse events resulting from medical errors -
More than half could have been prevented.
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