Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after "To Err Is Human"
This report assesses the state of patient safety in health care, advocating for a total systems approach across the continuum of care and establishment of a culture of safety, and calling for action by government, regulators, health professionals, and others to place higher priority on patient safety improvement and implementation science.
Highlights
- Report: 8 specific recommendations to accelerate progress based on a total systems approach and a culture of safety
- Executive Summary
- Infographic: The State of Patient Safety Fifteen Years after "To Err Is Human"
- Infographic: Eight Recommendations for Achieving Total Systems Safety
National Patient Safety Foundation. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Boston: National Patient Safety Foundation; 2015.
Note: French, Italian, Spanish, and Portuguese translations also available for download.
Fifteen years after the Institute of Medicine published the report, To Err Is Human, which brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response. The National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.
The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.
The report makes eight recommendations:
- Ensure that leaders establish and sustain a safety culture
- Create centralized and coordinated oversight of patient safety
- Create a common set of safety metrics that reflect meaningful outcomes
- Increase funding for research in patient safety and implementation science
- Address safety across the entire care continuum
- Support the health care workforce
- Partner with patients and families for the safest care
- Ensure that technology is safe and optimized to improve patient safety
Two accompanying infographics are also available:
- The State of Patient Safety Fifteen Years after "To Err Is Human"
- Eight Recommendations for Achieving Total Systems Safety
Convening the expert panel and the resulting report was made possible in part through a generous grant from AIG (American International Group, Inc.) in support of the advancement of the patient safety mission. AIG had no influence on the report direction or its content.
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