Need a candid response to the following:

Each of the four recommendations aims to improve healthcare from an approach at solving the problem from a previously noted factor of harm. One that solves the most harm and creates the most opportunity from my perspective is "creating safety systems inside health care organizations through the implementation of safe practices at the delivery level" (IOM, 2000). In doing this the healthcare organizations are practicing in the daily routine of the services performed an actively engaged method to reduce errors and to protect patients from harm due to seeking help for another issue. The need for this is most shown in the medical error rate for surgeries leaving foreign objects within the patient or performing the surgery on the wrong site.

"URFOs were the top sentinel event reported to The Joint Commission in 2017 (124 reported) and again in 2018 (121 reported). A total of 104 incidents of wrong-patient, wrong-site, wrong-procedure events were reported in 2017, with another 98 reported in 2018" (Pellegrini, 2020). This is illustrative of the need for organizations to go further in the safety improvements to lower this to a goal of zero reported incidences per year. If surgeons and those working within the surgical environment would look at what causes these types of errors and place the question of why to find the root cause of the issue then there could be significant work towards making a zero error goal a reality.

Although using surgeons and surgery for the example this root cause solution can help in all areas of healthcare since finding the root cause helps leaders and managers implement strategies that have the best chances of success. It is important again then to remember that it takes continuous quality efforts to sustain the highest level of care. In being lax towards initiatives they can take second priority to other goals and within healthcare there needs to be strong efforts to reducing all chance of harm coming to the patient when being cared for by the healthcare system and employees.

"The nonprofit National Quality Forum has endorsed more than 500 performance metrics, including both process measures (such as level of compliance with guidelines for fighting infections) and outcome measures (such as mortality)" (Bielaszka-DuVernay, 2011). This seems to have been a push to the efforts of supporting "identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients" (IOM,2000). In using performance metrics it helps those within the organization who evaluate and help better outcomes to see how the practices used are holding to averages of other healthcare systems or national metrics.

According to various references and articles it seems that one of the largest benefits to patient safety is in the awareness the IOM report and recommendations caused in the shift from complete innovation to best practices in the delivery of care and placing emphasis on patient safety. As leaders continue to push safety efforts from within the organization and as illustrated earlier practitioners also play a vital role in the development, awareness, and sustained efforts it will take to reduce medical errors to the near zero harm ratio desired. This takes investment from managers and leaders to invest the time, resources that are needed to these continuous safety improvement efforts.

References:

Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. Executive Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK225179/

Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25077248

Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System.

Washington, DC: The National Academies Press. https://doi.org/10.17226/9728.

MedScape. February 12, 2023. The Institute of Medicine Report on Medical Errors: Misunderstanding Can Do Harm. Retrieved from: https://www.medscape.com/viewarticle/418841_5

Pellegrini, Carlos, S. February 1^st, 2020. Revisiting To Err Is Human 20 years later. Bulletin of the American College of Surgeons. Retrieved from: https://bulletin.facs.org/2020/02/revisiting-to-err-is-human-20-years-later/