It has been more than eight years since the Institute of Medicine (IOM) released its groundbreaking report, "To Err Is Human: Building a Safer Health System," which triggered renewed attention to the problem of medical errors.1 In that time, numerous patient safety initiatives in the public and private sectors have been launched, and the National Patient Safety Goals (NPSGs) from the Joint Commission (JC) have taken on renewed importance.
Medical errors exact a high price in human life and costs to the healthcare system. As many as 98,000 Americans die annually as a result of medical errors. According to the Institute for Healthcare Improvement (IHI), patient safety improvements represent not only a professional and moral imperative, but also a tangible impact on the financial bottom line for healthcare institutions. The IOM has estimated that medical errors resulting in injury cost as much as $29 billion each year, over half of which reflects healthcare costs.2 Bates3 studied the impact of medication errors on a healthcare organization and discovered that preventable adverse drug events in two teaching hospitals caused an increase in length of stay of 4.6 days, at a cost of $4,685 each. He also reported that the overall rate of adverse drug events was 6.5 per 100 admissions, of which 28 percent were judged to be preventable — almost two of every 100 admissions. Another example of the cost of poor quality is hospital-acquired bloodstream infections that prolong a patient’s hospitalization by a mean of seven days. Estimates of attributable cost per bloodstream infection range between $3,700 and $29,000.4
