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To Err Is Human: Building a Safer Health System (2000)
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ISBN 978-0-309-06837-6 | DOI 10.17226/9728
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To Err Is Human: Building a Safer Health System
To Err Is Human
Building a Safer Health System
Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson, Editors
Committee on Quality of Health Care in America
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
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NOTICE: The project that is the subject of this report was approved by the Governing
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for their special competences and with regard for appropriate balance.
Support for this project was provided by The National Research Council and The
Commonwealth Fund. The views presented in this report are those of the Institute of
Medicine Committee on the Quality of Health Care in America and are not necessarily
those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
To err is human : building a safer health system / Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson, editors.
p. cm
Includes bibliographical references and index.
ISBN 0-309-06837-1
1. Medical errors—Prevention. I. Kohn, Linda T. II. Corrigan, Janet. III.
Donaldson, Molla S.
R729.8.T6 2000
362.1—dc21
99-088993
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To Err Is Human: Building a Safer Health System
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To Err Is Human: Building a Safer Health System
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To Err Is Human: Building a Safer Health System
COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA
WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg
Foundation, Battle Creek, MI
DONALD M. BERWICK, President and CEO, Institute for Healthcare
Improvement, Boston
J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta
LONNIE R. BRISTOW, Past President, American Medical Association,
Walnut Creek, CA
CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy
Initiatives, General Electric Company, Fairfield, CT
CHRISTINE K. CASSEL, Professor and Chairman, Department of
Geriatrics and Adult Development, Mount Sinai School of Medicine,
New York City
MARK R. CHASSIN, Professor and Chairman, Department of Health Policy,
Mount Sinai School of Medicine, New York City
MOLLY JOEL COYE, Senior Vice President and Director, West Coast
Office, The Lewin Group, San Francisco
DON E. DETMER, Dennis Gillings Professor of Health Management,
University of Cambridge, UK
JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management
Corporation, Boston
BRENT JAMES, Executive Director, Intermountain Health Care, Institute
for Health Care Delivery Research, Salt Lake City, UT
DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health
Plan, Inc., Oakland, CA
LUCIAN LEAPE, Adjunct Professor, Harvard School of Public Health
ARTHUR LEVIN, Director, Center for Medical Consumers, New York City
RHONDA ROBINSON-BEALE, Executive Medical Director, Managed
Care Management and Clinical Programs, Blue Cross Blue Shield of
Michigan, Southfield
JOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University of
California at Irvine College of Medicine
ARTHUR SOUTHAM, Partner, 2C Solutions, Northridge, CA
MARY WAKEFIELD, Director, Center for Health Policy and Ethics,
George Mason University
GAIL L. WARDEN, President and CEO, Henry Ford Health System,
Detroit
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Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Study Staff
JANET M. CORRIGAN, Director, Division of Health Care Services,
Director, Quality of Health Care in America Project
MOLLA S. DONALDSON, Project Co-Director
LINDA T. KOHN, Project Co-Director
TRACY McKAY, Research Assistant
KELLY C. PIKE, Senior Project Assistant
Auxiliary Staff
MIKE EDINGTON, Managing Editor
KAY C. HARRIS, Financial Advisor
SUZANNE MILLER, Senior Project Assistant
Copy Editor
FLORENCE POILLON
vi
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Reviewers
T
his report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine in making the published report as sound as possible and to ensure that the report
meets institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and the draft manuscript remain
confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the
review of this report:
GERALDINE BEDNASH, Executive Director, American Association of
Colleges of Nursing, Washington, DC
PETER BOUXSEIN, Visiting Scholar, Institute of Medicine, Washington,
DC
JOHN COLMERS, Executive Director, Maryland Health Care Cost and
Access Commission, Baltimore
JEFFREY COOPER, Director, Partners Biomedical Engineering Group,
Massachusetts General Hospital, Boston
ROBERT HELMREICH, Professor, University of Texas at Austin
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To Err Is Human: Building a Safer Health System
viii
REVIEWERS
LOIS KERCHER, Vice President for Nursing, Sentara-Virginia Beach
General Hospital, Virginia Beach, VA
GORDON MOORE, Associate Chief Medical Officer, Strong Health,
Rochester, NY
ALAN NELSON, Associate Executive Vice President, American College of
Physicians/American Society of Internal Medicine, Washington, DC
LEE NEWCOMER, Chief Medical Officer, United HealthCare Corporation,
Minnetonka, MN
MARY JANE OSBORN, University of Connecticut Health Center
ELLISON PIERCE, Executive Director, Anesthesia Patient Safety
Foundation, Boston
Although the individuals acknowledged have provided valuable comments and suggestions, responsibility for the final contents of the report
rests solely with the authoring committee and the Institute of Medicine.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Preface
T
o Err Is Human: Building a Safer Health System. The title of this
report encapsulates its purpose. Human beings, in all lines of work,
make errors. Errors can be prevented by designing systems that make
it hard for people to do the wrong thing and easy for people to do the right
thing. Cars are designed so that drivers cannot start them while in reverse
because that prevents accidents. Work schedules for pilots are designed so
they don’t fly too many consecutive hours without rest because alertness and
performance are compromised.
In health care, building a safer system means designing processes of care
to ensure that patients are safe from accidental injury. When agreement has
been reached to pursue a course of medical treatment, patients should have
the assurance that it will proceed correctly and safely so they have the best
chance possible of achieving the desired outcome.
This report describes a serious concern in health care that, if discussed
at all, is discussed only behind closed doors. As health care and the system
that delivers it become more complex, the opportunities for errors abound.
Correcting this will require a concerted effort by the professions, health care
organizations, purchasers, consumers, regulators and policy-makers. Traditional clinical boundaries and a culture of blame must be broken down. But
most importantly, we must systematically design safety into processes of care.
This report is part of larger project examining the quality of health care
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To Err Is Human: Building a Safer Health System
x
PREFACE
in America and how to achieve a threshold change in quality. The committee
has focused its initial attention on quality concerns that fall into the category
of medical errors. There are several reasons for this. First, errors are responsible for an immense burden of patient injury, suffering and death. Second,
errors in the provision of health services, whether they result in injury or
expose the patient to the risk of injury, are events that everyone agrees just
shouldn’t happen. Third, errors are readily understandable to the American
public. Fourth, there is a sizable body of knowledge and very successful
experiences in other industries to draw upon in tackling the safety problems
of the health care industry. Fifth, the health care delivery system is rapidly
evolving and undergoing substantial redesign, which may introduce improvements, but also new hazards. Over the next year, the committee will be
examining other quality issues, such as problems of overuse and underuse.
The Quality of Health Care in America project is largely supported with
income from an endowment established within the IOM by the Howard
Hughes Medical Institute and income from an endowment established for
the National Research Council by the Kellogg Foundation. The Commonwealth Fund provided generous support for a workshop to convene medical, nursing and pharmacy professionals for input into this specific report.
The National Academy for State Health Policy assisted by convening a focus
group of state legislative and regulatory leaders to discuss patient safety.
Thirty-eight people were involved in producing this report. The Subcommittee on Creating an External Environment for Quality, under the direction of J. Cris Bisgard and Molly Joel Coye, dealt with a series of complex
and sensitive issues, always maintaining a spirit of compromise and respect.
Additionally the Subcommittee on Designing the Health System of the 21st
Century, under the direction of Donald Berwick, had to balance the challenges faced by health care organizations with the need to continually push
out boundaries and not accept limitations. Lastly, under the direction of
Janet Corrigan, excellent staff support has been provided by Linda Kohn,
Molla Donaldson, Tracy McKay, and Kelly Pike.
At some point in our lives, each of us will probably be a patient in the
health care system. It is hoped that this report can serve as a call to action
that will illuminate a problem to which we are all vulnerable.
William C. Richardson, Ph.D.
Chair
November 1999
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Foreword
T
his report is the first in a series of reports to be produced by the
Quality of Health Care in America project. The Quality of Health
Care in America project was initiated by the Institute of Medicine in
June 1998 with the charge of developing a strategy that will result in a threshold improvement in quality over the next ten years.
Under the direction of Chairman William C. Richardson, the Quality of
Health Care in America Committee is directed to:
• review and synthesize findings in the literature pertaining to the quality of care provided in the health care system;
• develop a communications strategy for raising the awareness of the
general public and key stakeholders of quality of care concerns and opportunities for improvement;
• articulate a policy framework that will provide positive incentives to
improve quality and foster accountability;
• identify characteristics and factors that enable or encourage providers, health care organizations, health plans and communities to continuously
improve the quality of care; and
• develop a research agenda in areas of continued uncertainty.
This first report on patient safety addresses a serious issue affecting the
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To Err Is Human: Building a Safer Health System
xii
FOREWORD
quality of health care. Future reports in this series will address other qualityrelated issues and cover areas such as re-designing the health care delivery
system for the 21st Century, aligning financial incentives to reward quality
care and the critical role of information technology as a tool for measuring
and understanding quality. Additional reports will be produced throughout
the coming year.
The Quality of Health Care in America project continues IOM’s longstanding focus on quality of care issues. The IOM National Roundtable on
Health Care Quality described how variable the quality of health care is in
this country and highlighted the urgent need for improving it. A recent report issued by the IOM National Cancer Policy Board concluded that there
is a wide gulf between ideal cancer care and the reality that many Americans
experience with cancer care.
The IOM will continue to call for a comprehensive and strong response
to this most urgent issue facing the American people. This current report on
patient safety further reinforces our conviction that we cannot wait any
longer.
Kenneth I. Shine, M.D.
President, Institute of Medicine
November 1999
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Acknowledgments
T
he Committee on the Quality of Health Care in America first and
foremost acknowledges the tremendous contribution by the members of two subcommittees. Both subcommittees spent many hours
working through a set of exceedingly complex issues, ranging from topics
related to expectations from the health care delivery system to the details of
how reporting systems work. Although individual subcommittee members
raised different perspectives on a variety of issues, there was no disagreement on the ultimate goal of making care safer for patients. Without the
efforts of the two subcommittees, this report would not have happened. We
take this opportunity to thank each and every subcommittee member for
their contribution.
SUBCOMMITTEE ON CREATING AN ENVIRONMENT FOR
QUALITY IN HEALTH CARE
J. Cris Bisgard (Cochair), Delta Air Lines, Inc.; Molly Joel Coye, (Cochair), The Lewin Group; Phyllis C. Borzi, The George Washington University; Charles R. Buck, Jr., General Electric Company; Jon Christianson, University of Minnesota; Charles Cutler, formerly of The Prudential HealthCare;
Mary Jane England, Washington Business Group on Health; George J.
Isham, HealthPartners; Brent James, Intermountain Health Care; Roz D.
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Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
xiv
ACKNOWLEDGMENTS
Lasker, New York Academy of Medicine; Lucian Leape, Harvard School of
Public Health; Patricia A. Riley, National Academy of State Health Policy;
Gerald M. Shea, American Federation of Labor and Congress of Industrial
Organizations; Gail L. Warden, Henry Ford Health System; A. Eugene
Washington, University of California, San Francisco School of Medicine;
and Andrew Webber, Consumer Coalition for Health Care Quality.
SUBCOMMITTEE ON BUILDING THE 21ST CENTURY
HEALTH CARE SYSTEM
Don M. Berwick (Chair), Institute for Healthcare Improvement; Christine K. Cassel, Mount Sinai School of Medicine; Rodney Dueck,
HealthSystem Minnesota; Jerome H. Grossman, Lion Gate Management
Corporation; John E. Kelsch, Consultant in Total Quality; Risa LavizzoMourey, University of Pennsylvania; Arthur Levin, Center for Medical Consumers; Eugene C. Nelson, Hitchcock Medical Center; Thomas Nolan, Associates in Proc-ess Improvement; Gail J. Povar, Cameron Medical Group;
James L. Reinertsen, CareGroup; Joseph E. Scherger, University of California, Irvine; Stephen M. Shortell, University of California, Berkeley; Mary
Wakefield, George Mason University; and Kevin Weiss, Rush Primary Care
Institute.
A number of people willingly and generously gave their time and expertise as the committee and both subcommittees conducted their deliberations. Their contributions are acknowledged here.
Participants in the Roundtable on the Role of the Health Professions in
Improving Patient Safety provided many useful insights reflected in the final
report. They included: J. Cris Bisgard, Delta Air Lines, Inc.; Terry P.
Clemmer, Intermountain Health Care; Leo J. Dunn, Virginia Commonwealth University; James Espinosa, Overlook Hospital; Paul Friedmann, Bay
State Hospital; David M. Gaba, V.A. Palo Alto HCS; Larry A. Green, American Academy of Family Physicians; Paul F. Griner, Association of American
Medical Colleges; Charles Douglas Hepler, University of Florida; Carolyn
Hutcherson, Health Policy Consultant; Lucian L. Leape, Harvard School of
Public Health; William C. Nugent, Dartmouth Hitchcock Medical Center;
Ellison C. Pierce Jr., Anesthesia Patient Safety Foundation; Bernard Rosof,
Huntington Hospital; Carol Taylor, Georgetown University; Mary
Wakefield, George Mason University; and Richard Womer, Children’s Hospital of Philadelphia.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
ACKNOWLEDGMENTS
xv
We are also grateful to the state representatives who participated in the
focus group on patient safety convened by the National Academy for State
Health Policy, including: Anne Barry, Minnesota Department of Finance;
Jane Beyer, Washington State House of Representatives; Maureen Booth,
National Academy of State Health Policy Fellow; Eileen Cody, Washington
State House of Representatives; John Colmers, Maryland Health Care Access and Cost Commission; Patrick Finnerty, Virginia Joint Commission on
Health Care; John Frazer, Delaware Office of the Controller General; Lori
Gerhard, Commonwealth of Pennsylvania, Department of Health; Jeffrey
Gregg, State of Florida, Agency for Health Care Administration; Frederick
Heigel, New York Bureau of Hospital and Primary Care Services; John
LaCour, Louisiana Department of Health and Hospitals; Maureen Maigret,
Rhode Island Lieutenant Governor’s Office; Angela Monson, Oklahoma
State Senate; Catherine Morris, New Jersey State Department of Health;
Danielle Noe, Kansas Office of the Governor; Susan Reinhard, New Jersey
Department of Health and Senior Services; Trish Riley, National Academy
for State Health Policy; Dan Rubin, Washington State Department of
Health; Brent Ewig, ASTHO; Kathy Weaver, Indiana State Department of
Health; and Robert Zimmerman, Pennsylvania Department of Health.
A number of people at the state health departments generously provided information about the adverse event reporting program in their state.
The committee thanks the following people for their time and help: Karen
Logan, California; Jackie Starr-Bocian, Colorado; Julie Moore, Connecticut; Anna Polk, Florida; Mary Kabril, Kansas; Lee Kelly, Massachusetts;
Vanessa Phipps, Mississippi; Nancy Garvey, New Jersey; Ellen Flink, New
York; Kathryn Kimmet, Ohio; Larry Stoller, Jim Steel and Elaine Gibble,
Pennsylvania; Laurie Round, Rhode Island; and Connie Richards, South
Dakota. In addition, Renee Mallett at the Ohio Hospital Association also
offered assistance.
From the Food and Drug Administration, the Committee especially recognizes the contributions of Janet Woodcock, Director, Center for Drug
Evaluation and Research; Ralph Lillie, Director, Office of Post-Marketing
Drug Risk Assessment; Susan Gardner, Deputy Director, Center for Devices
and Radiological Health; Jerry Phillips, Associate Director, Medication Error Program and Peter Carstenson, Senior Systems Engineer, Division of
Device User Programs and System Analysis.
Assistance from the Agency for Healthcare Research and Quality came
from John M. Eisenberg, Administrator; Gregg Meyer, Director of the Center for Quality Measurement and Improvement; Nancy Foster, Coordinator
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
xvi
ACKNOWLEDGMENTS
for Quality Activities and Marge Keyes, Project Officer. At the Health Care
Financing Administration, Jeff Kang, Director, Clinical Standards and Quality and Tim Cuerdon, Office of Clinical Standards and Quality were especially helpful. At the Veterans Health Administration, Kenneth Kizer, former
Undersecretary for Health and Ronald Goldman, Office of Performance
and Quality shared their views on how to create a culture of safety inside
large health care organizations.
Other individuals provided data, information and background that significantly contributed to the committee’s understanding of patient safety.
The committee would like to particularly acknowledge the contributions of
Charles Billings, now at Ohio State University and designer of the Aviation
Safety Reporting System; Linda Blank at the American Board of Internal
Medicine; Michael Cohen at the Institute for Safe Medication Practices;
Linda Connell at the Aviation Safety Reporting System at NASA/Ames Research Center; Diane Cousins and Fay Menacker at U.S. Pharmacopeia,
Martin Hatlie and Eleanor Vogt at the National Patient Safety Foundation;
Henry Manasse and Colleen O’Malley at the American Society of HealthSystem Pharmacists; Cynthia Null at the Human Factors Research and Technology Division at NASA/Ames Research Center; Eric Thomas, at the University of Texas at Houston; Margaret VanAmringe at the Joint Commission
on Accreditation of Health Care Organizations; and Karen Williams at the
National Pharmaceuticals Council.
A special thanks is offered to Randall R. Bovbjerg and David W. Shapiro
for preparing a paper on the legal discovery of data reported to adverse
event reporting systems. Their paper significantly contributed to Chapter 6
of this report, although the conclusions and findings are the full responsibility of the committee (readers should not interpret their input as legal advice
nor representing the views of their employing organizations).
A special thanks is also provided to colleagues at the IOM. Claudia Carl
and Mike Edington provided assistance during the report review and preparation stages. Ellen Agard and Mel Worth significantly contributed to the
case study that is used in the report. Wilhelmine Miller expertly arranged
the workshop with physicians, nurses and pharmacists and ensured a successful meeting. Suzanne Miller provided important assistance to the literature review. Tracy McKay provided help throughout the project, from coordinating literature searches to overseeing the editing of the report. A special
thanks is offered to Kelly Pike. Her outstanding support and attention to
detail was critical to the success of this report. Her assistance was always
offered with enthusiasm and good cheer.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
ACKNOWLEDGMENTS
xvii
Finally, the committee acknowledges the generous support from the
National Research Council and the Institute of Medicine to conduct this
work. Additionally, the committee thanks Brian Biles for his interest in this
work and gratefully acknowledges the contribution of The Commonwealth
Fund, a New York City-based private independent foundation. The views
presented here are those of the authors and not necessarily those of The
Commonwealth Fund, its directors, officers or staff.
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Contents
EXECUTIVE SUMMARY
1
2
3
1
A COMPREHENSIVE APPROACH TO IMPROVING
PATIENT SAFETY
Patient Safety: A Critical Component of Quality, 18
Organization of the Report, 21
ERRORS IN HEALTH CARE: A LEADING CAUSE OF
DEATH AND INJURY
Introduction, 27
How Frequently Do Errors Occur?, 29
Factors That Contribute to Errors, 35
The Cost of Errors, 40
Public Perceptions of Safety, 42
WHY DO ERRORS HAPPEN?
Why Do Accidents Happen?, 51
Are Some Types of Systems More Prone to Accidents?, 58
Research on Human Factors, 63
Summary, 65
xix
Copyright National Academy of Sciences. All rights reserved.
17
26
49
To Err Is Human: Building a Safer Health System
xx
4
CONTENTS
BUILDING LEADERSHIP AND KNOWLEDGE FOR
PATIENT SAFETY
Recommendations, 69
Why a Center for Patient Safety Is Needed, 70
How Other Industries Have Become Safer, 71
Options for Establishing a Center for Patient Safety, 75
Functions of the Center for Patient Safety, 78
Resources Required for a Center for Patient Safety, 82
69
5
ERROR REPORTING SYSTEMS
Recommendations, 87
Review of Existing Reporting Systems in Health Care, 90
Discussion of Committee Recommendations, 101
6
PROTECTING VOLUNTARY REPORTING SYSTEMS
FROM LEGAL DISCOVERY
109
Recommendation, 111
Introduction, 112
The Basic Law of Evidence and Discoverability of Error-Related
Information, 113
Legal Protections Against Discovery of Information About Errors, 117
Statutory Protections Specific to Particular Reporting Systems, 121
Practical Protections Against the Discovery of Data on Errors, 124
Summary, 127
7
SETTING PERFORMANCE STANDARDS AND
EXPECTATIONS FOR PATIENT SAFETY
Recommendations, 133
Current Approaches for Setting Standards in Health Care, 136
Performance Standards and Expectations for
Health Care Organizations, 137
Standards for Health Professionals, 141
Standards for Drugs and Devices, 148
Summary, 151
8
CREATING SAFETY SYSTEMS IN HEALTH CARE
ORGANIZATIONS
Recommendations, 156
Introduction, 158
Copyright National Academy of Sciences. All rights reserved.
86
132
155
To Err Is Human: Building a Safer Health System
CONTENTS
xxi
Key Safety Design Concepts, 162
Principles for the Design of Safety Systems in
Health Care Organizations, 165
Medication Safety, 182
Summary, 197
APPENDIXES
A Background and Methodology
B Glossary and Acronyms
C Literature Summary
D Characteristics of State Adverse Event Reporting Systems
E Safety Activities in Health Care Organizations
205
210
215
254
266
INDEX
273
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
To Err Is Human
Building a Safer Health System
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Copyright National Academy of Sciences. All rights reserved.
To Err Is Human: Building a Safer Health System
Executive
Summary
T
he knowledgeable health reporter for the Boston Globe, Betsy
Lehman, died from an overdose during chemotherapy. Willie King
had the wrong leg amputated. Ben Kolb was eight years old when he
died during “minor” surgery due to a drug mix-up.1
These horrific cases that make the headlines are just the tip of the iceberg. Two large studies, one conducted in Colorado and Utah and the other
in New York, found that adverse events occurred in 2.9 and 3.7 percent of
hospitalizations, respectively.2 In Colorado and Utah hospitals, 6.6 percent
of adverse events led to death, as compared with 13.6 percent in New York
hospitals. In both of these studies, over half of these adverse events resulted
from medical errors and could have been prevented.
When extrapolated to the over 33.6 million admissions to U.S. hospitals
in 1997, the results of the study in Colorado and Utah imply that at least
44,000 Americans die each year as a result of medical errors.3 The results of
the New York Study suggest the number may be as high as 98,000.4 Even
when using the lower estimate, deaths due to medical errors exceed the
number attributable to the 8th-leading cause of death.5 More people die in
a given year as a result of medical errors than from motor vehicle accidents
(43,458), breast cancer (42,297), or AIDS (16,516).6
Total national costs (lost income, lost household production, disability
and health care costs) of preventable adverse events (medical errors result1
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To Err Is Human: Building a Safer Health System
2
TO ERR IS HUMAN
ing in injury) are estimated to be betwee