To err is human: strategies for ensuring patient safety and quality when caring for children.

IN 1998, PRESIDENT CLINTON appointed a National Advisory Commission on Consumer Protection and Quality in the Health Industry. The purpose of this Commission was to begin a national dialogue about patient safety in the context of quality health care. Several prominent nurses were appointed to the Commission, including Mary Wakefield, PhD, RN, FAAN, Director of the Center for Health Policy, Research and Ethics, at George Mason University and Beverly Malone, PhD, RN, FAAN, former President of the American Nurses Association and now Secretary General of the Royal College of Nursing in London, England. A national report, entitled “Quality First: Better Health Care for All Americans” (1998), was developed that recommended several steps to improve patient safety while ensuring quality health care. The number one recommendation from the President’s Advisory Commission’s report was the need to reduce health errors in the United States health care system. As a result of the President’s Advisory Commission’s report, the Institute of Medicine (IOM) established the Committee on Health Care Quality in America. The first report of the IOM Committee, entitled “To Err is Human: Building a Safer Health System,” was developed and focused predominantly on patient safety. The IOM report estimated that 44,000 to 98,000 people die each year as a result, at least in part, of medical errors (Institute of Medicine, 2000). The findings from this report documented the need for improving patient safety in the nation. Soon after the IOM report was released, newspapers, such as USA Today, announced “Medical mistakes were the eighth top killer in the United States” (1999). Unfortunately, the nursing profession received the brunt of the blame when newspapers such as the Chicago Tribune reported in September 2000, “Nursing Accidents Unleash Silent Killer: Misuse of Medical Pumps Leads to Death” and “Nursing Mistakes Kill, Injure Thousands: Cost-cutting Exacts Toll on Patients, Hospital Staffs” (Berens, 2000). This evoked a national crisis and a call for action by nurses, health care providers, and health systems to reduce medical errors and to ensure patient safety in America’s health care systems. Some of the key findings noted in the IOM report included that the people most at risk for medical errors were those patients admitted to high risk hospital departments such as critical care units, emergency departments, and pediatric units (IOM, 2000). Moreover, key findings indicated that errors occur because of system failures, particularly those related to adverse drug events that result in injury to the patient. The lack of an effective system or nonpunitive system of reporting adverse drug events such as overdoses and allergic or idiosyncratic reactions is the most common example of a system failure (Health Resources Services Administration, 2000). It is also imperative that benign errors or “near misses” be reported. Systems that collect and analyze such incidents have more information available to design safer systems of care (IOM, 2000; Wakefield & Maddox, 2000). “Systems should be designed to encourage reporting of adverse events so that feedback can be provided to health care professionals so as to make evident the benefits of alterations to practice methods” (Health Resources Services Administration, 2000, p. 12). From the College of Nursing & Health Science, Center for Health Policy, Research & Ethics, George Mason University, Fairfax, VA. Address reprint requests to Stephanie L. Ferguson, PhD, RN, FAAN, 46809 Trailwood Place, Sterling, VA 20165. Copyright © 2001 by W.B. Saunders Company 0882-5963/01/1606-0008$35.00/0 doi:10.1053/jpdn.2001.29699