Institute of Medicine Report

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

Excerpt: Anesthesiology is an example of a local, but complex, high-risk, dynamic patient care system in which there has been notably reduced error. Responding to rising malpractice premiums in the mid-1980s, anesthesiologists confronted the safety issues presented by the need for continuing vigilance during long operations punctuated by the need for rapid problem evaluation and action. They were faced with a heterogeneity of design in anesthesia devices; fatigue and sleep deprivation; and competing institutional, professional, and patient care priorities. By a combination of technological advances (most notably the pulse oximeter), standardization of equipment, and changes in training, they were able to bring about major, sustained, widespread reduction in morbidity and mortality attributable to the administration of anesthesia.

Organization-wide systems, on the other hand, are implemented and monitored at the level of a health care organization. These include programs and processes that cross departmental lines and units. In hospitals, infection control and medication administration are examples of organization-wide systems that encompass externally imposed regulations, institutional policies and procedures, and the actions of individuals who must provide potentially toxic materials at the right time to the right patient.