Reflections on “To Err is Human: Building a Safer Health System,” 25 years later–and implications for today

When the Institute of Medicine (IOM) released its landmark report, To Err is Human: Building a Safer Health System, in November 1999, blunt and urgent headlines stoked a public outcry. The New York Times wrote, “Hospital Errors Kill Thousands Each Year,” while the Washington Post printed, “Medical Mistakes Kill 44,000 to 98,000 Americans a Year.” The Associated Press shared “Doctor, Hospital Mistakes Kill 98,000 a Year.” The shock value and directness helped launch healthcare’s patient safety and quality movement. 

At the time, FUHN’s Data Analytics Consultant Mark Sonneborn was vice president of data services for the Michigan Health & Hospital Association. When Sonneborn took a similar position at the Minnesota Hospital Association (MHA) in October 2004, he had a transformative–and daunting–role: In 2003, Minnesota was the first state to establish a mandatory adverse health event reporting system. The Adverse Health Events Reporting law requires Minnesota hospitals, freestanding outpatient surgical centers, and regional treatment centers to report 28 “never events” identified by the National Quality Forum such as operating on the wrong body part, discharge of an infant to the wrong person, death or serious disability due to medication error, and more. 

In reflecting on the significance of To Err is Human, Sonneborn said, “Before that report came out, medical errors were taboo and embarrassing to the field. But medical leaders recognized that it was important to learn from the mistakes, so they didn’t happen to anybody else.” 

In the years following the IOM report and the new law, Sonneborn said MHA focused on reporting, education, and staff training around patient safety. Quality committees reviewed the adverse health event reports to examine what they saw, what they could learn, and what they needed to design in their systems. Sonneborn and the MHA team provided the data analytics to guide the changes. 

“It’s okay to say we’ve got work to do.”

According to Sonneborn, the ideal for the adverse health event reporting system is to get to zero events. To move towards zero, you need to study every event, learn, and make systemic changes that can reduce preventable harm and improve patient safety. The learnings are shared with the field, too, which is important for incidents as rare as adverse health events. If nothing gets reported, nothing can be learned or improved.

Sonneborn likens adverse health events to plane crashes. Systems exist to make aviation as safe as possible. But crashes, though rare, still happen. When they do, the Federal Aviation Administration’s Office of Accident Investigation & Prevention thoroughly reviews the incident to determine what happened and how it could have been prevented. The process involves examining everything from the plane’s manufacturing to pilot error, weather conditions, missed communications, and more. 

To Sonneborn, what’s significant about the IOM report and subsequent adverse health event reporting 25 years later is that “it’s okay to say we’ve got work to do.” Just like plane crashes, adverse health events happen, and they need thorough investigations–and subsequent prevention measures–to save and improve people’s lives. 

Today, Sonneborn carries this mantra into his work with FUHN member clinics. Sonneborn helps lead the FUHN Quality Committee and notes that there are quality measures where FUHN clinics are not yet at the national UDS average (e.g., cancer screening rates or childhood immunizations). While closing rates may seem daunting and unattainable, Sonneborn remains optimistic and looks to federally qualified health centers (FQHCs) that have achieved results with similar patient populations. 

Sonneborn said, “If you shoot for a target that’s far away–and make progress–you’re moving forward.”