Discussion, you will review these recommendations and consider the role of health
information technology in helping address concerns presented in the report.
The Effects of “To Err Is Human” in Nursing Practice
Patients fail to receive quality care today because most health care delivery incidences
are characterized by cases of error which tend to undermine patient safety. According to the
Institute of Medicine (IOM) (1999), a medical error occurs when a healthcare provider either
utilizes an evil action plan in an attempt to solve a patient’s problem or selects the right action
plan but which generates undesirable results. In its “To Err is Human” report, the IOM (1999) is
concerned that medical errors inflict pain on patients and raise healthcare costs for individuals
THE EFFECTS OF “TO ERR IS HUMAN” IN NURSING PRACTICE 2
and healthcare institutions. The report details some recommendations that should be
implemented by healthcare institutions, agencies, and the government to improve patient safety
and minimize costs. Since the report was published, governments, health care institutions, and
agencies have made appropriate changes to their systems to help improve patient safety, with one
of them being the development of information technology (Leape and Berwick, 2005).
The development of information technology has significantly helped to address the
concerns about patient safety raised in the “To Err is Human” report. As Plawecki and Amrheinn
(2009) explain, most medical errors involve; leaving foreign materials inside a patient’s body
after conducting a surgery, administration of wrong medication to patients, and lack of adherence
to the right procedures when delivering care. According to Wakefield (2008), these errors occur
because healthcare providers are not aware of the degree at which errors occur in their healthcare
settings. With the development of information technology, the accuracy with which care is
delivered has considerably improved. Additionally, information technology assists healthcare
providers in adhering to the right procedures when delivering care. This helps to minimize
unnecessary costs associated with repeated visits, lost income, and reduced household
productivity mentioned in “To Err is Human” report (Leape and Berwick, 2005).
Since “To Err is Human” report was published, informatics has greatly assisted in
improving health care safety in my organization. Before the publication of the report, my
organization relied on traditional forms of healthcare delivery which were associated with
increased cases of medical error. For instance, my organization relied on paper records to store
patient information. The recorded information was only available to specific healthcare
providers, a factor that prevented the patient from assessing the legitimacy of the physicians’
actions on their healthcare needs. My organization has since implemented an electronic medical
THE EFFECTS OF “TO ERR IS HUMAN” IN NURSING PRACTICE 3
records system that allows all stakeholders involved in a patient’s case to share knowledge
concerning how a given health problem should be approached (Wakefield, 2008). This has
significantly helped to minimize medical errors that used to occur during healthcare delivery.
The IOM (1999) recommends implementation of safety systems in health care
organizations to promote safe practices during care delivery. By implementing an electronic
medical records system as part of its efforts towards improving patient safety, my organization
has demonstrated its commitment to the IOM (1999) recommendations. However, the
organization still needs to make improvements on its stand concerning secrecy of professionals’
actions. My organization has done little to improve transparency and accountability among
health care providers. Currently, very few healthcare practitioners in the organization admit
mistakes due to fear of facing a lawsuit. This increases cases of medical errors in the
organization. The company should install a computerized system that will help to organize
activities of professionals, and that will record ‘who does what’ at any given time. This will help
to reduce medical errors by maximizing accountability and transparency among health care
providers.
References
Institute of Medicine. (1999). To err is human: Building a safer health system.
THE EFFECTS OF “TO ERR IS HUMAN” IN NURSING PRACTICE 4
Plawecki, L. & Amrhein, D. (2009). Clearing the err: Reporting serious adverse events and
“never events” in today’s health care system. Journal of Gerontological Nursing, 35(11):
26-19.ISS:0098-9134.
Wakefield, M. (2008). The quality chasm series: Implications for nursing. In R. G. Hughes (Ed),
Patient Safety and Quality: An evidence-based handbook for nurses. Rockville MD: U.S
Department of Health and Human Services.