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Landmark Institute of Medicine (IOM) report, To Err is Human is published.

The work of CHOPR researchers on patient safety and health outcomes began years before the initial publication of To Err is Human. In fact, it is widely known that our early investigations in the field played a key role in crafting the IOM Quality Reports.

It has been more than 20 years since the November 1999 publication, To Err is Human: Building a Safer Health System, and yet CHOPR continues extensive efforts to uncover what affects health outcomes and how policy can create a safer, better health system. CHOPR research and papers that followed the Report have helped shape healthcare policy and encourage new initiatives. 

The work of CHOPR researchers on patient safety and health outcomes began years before the initial publication of To Err is Human. In fact, it is widely known that our early investigations in the field played a key role in crafting the IOM Quality Reports. Our research findings are extensively referenced in the third and final installment of the 2003 quality series, Keeping Patients Safe: Transforming the Nurse Work Environment; the basic thesis being it would not be possible to keep patients safe unless the quality of the nurse work environment was substantially improved.

More recently, Dr. Matthew McHugh spoke at the National Academy of Medicine’s 2015 Richard & Hinda Rosenthal Symposium to mark the healthcare system’s progress since the release of the IOM Quality Reports. He addressed the extent to which problems still existed within the healthcare field, noting how the lack of empowerment nurses experience in the hospital organization system affects patient safety improvements.

“I think that much of the work that we have done has not focused as much on the environment, but on individual programs and interventions still at the individual level, rather than the systems level. I fear that without a focus on the organizational level, we should only expect marginal gains going forward.”

In 2018, Dr. Linda Aiken told Dr. Robert Wachter, a prominent academic-physician from the University of California, San Francisco, how and why nurse staffing and the work environment can affect patient safety and outcomes in a conversation on Perspectives on Safety for the Agency for Healthcare Research and Quality.

“Since the IOM report, we have been following up to see whether any evidence shows that the culture of patient safety actually has improved. We have empirical evidence through 2016 that suggests the culture of patient safety in hospitals has not changed enough.”