Write thoughts on how the development of information technology has helped address the concerns about patient safety raised in the To Err is Human report. Summarize how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.
Legal Issues
I
ve made a mistake. This
simple statement or its mere
thought is enough to strike fear
within the most experienced and
knowledgeable of health care pro

fessionals. No matter how many
times a procedure has been done or
a medication administered there is
always the likelihood of prevent

able error. Each year the public
is reminded of the potential for
mistakes as the media report medical
horror stories where for example
unknowing patients have surgery
performed on the wrong body part
a wrong medication administered
or a foreign object errantly left
inside their bodies. These reports
highlight the biggest fear of health
care workerstheir own fallibility.
Through carelessness assumption
overt act or omission the health
care professional can easily err
and cause harm to the patient. In
addition to the pain caused to the
patient health care providers also
understand the devastating impact
that such errors can wreak on their
own personal and professional lives.
The purpose of this article is to
About the Authors
Mr. Plawecki is Registered Nurse
Rehabilitation Hospital of Indiana In

dianapolis and Dr. Amrhein is Resident
Physician Family Practice Medicine Ball
Memorial Hospital Muncie Indiana.
The authors disclose that they have no
significant financial interests in any prod

uct or class of products discussed directly
or indirectly in this activity including
research support.
Address correspondence to Lawrence
H. Plawecki RN JD LLM Regis

tered Nurse Rehabilitation Hospital of
Indiana 4141 Shore Drive Indianapolis
IN 46254; e-mail: Lawrence.plawecki@
gmail.com.
doi:10.3928/00989134-20091016-01
Clearing the Err
Reporting Serious Adverse Events and Never Events in Todays Health Care System
Lawrence H. Plawecki RN JD LLM; and David W. Amrhein MD
Abstr
A
ct
Absent an infinitesimal percentage most Americans seek health care ser

vices due to a legitimate health issue. Fundamental within this relationship
is the understanding that health care professionals will do everything within
their power and expertise to alleviate the suffering of each patient they
treat. Unfortunately preventable medical errors do occur and the in

nocent patient is left to suffer. In 1999 the Institute of Medicine
released
t
o
e
rr Is
h
uman:
b
uilding A
s
afer
h
ealth
s
ystem
the
first mainstream publication calling for a change in the
culture of health care and the eradication of prevent

able medical errors. In the 10 years since its publica

tion federal and state governments and agencies
have been proactive in attempting to meet the
recommendations originally proposed in
t
o
e
rr Is
h
uman
. This article will review what has been ac

complished in this time frame.
iStockphoto.com/ Ireneusz Skorupa
JOGNonline.com
26
discuss the trend in todays health
care systems toward the reporting
of serious adverse events or never
events as well as the impactboth
impending and currenton the role
of geriatric nurses.
r
efocus
I
ng
A
nd
r
ebu
IL
d
I
ng
A
sA
fe He
AL
t
H
cA
re
s
ystem
In November 1999 the Insti

tute of Medicine (IOM) released a
profound call to action for everyone
involved in the health care commu

nity. This statement entitled
To Err
Is Human: Building A Safer Health
System
began with a grim statistic
estimating that between 44000 and
98000 people died per year from
preventable medical errors as hospi

tal patients. The IOM (1999) report
defined
medical error
as the use of a
wrong plan of action to achieve an
aim or the planned actions failure
to be completed as intended. In
economic terms these errors were
estimated to cost between $17 billion
and $29 billion per year across the
country (IOM 1999). These financial
estimates include the costs of lost
income lost household productivity
and the cost of the additional health
care necessitated by the errors (IOM
1999). The more specific recommen

dations posited by the IOM (1999)
for the prevention of medical errors
are discussed below.
The IOM (1999) report recom

mended a four-tiered approach to
achieve a better safety record:
l
Establishing a national focus
to create leadership research
tools and protocols to enhance the
knowledge base about safety.
l
Identifying and learning from
errors by developing a nationwide
public mandatory reporting system
and by encouraging health care
organizations and practitioners to
develop and participate in voluntary
reporting systems.
l
Raising performance standards
and expectations for improvements in
safety through the actions of oversight
organizations professional groups
and purchasers of health care.
l
Implementing safety systems
in health care organizations to ensure
safe practices at the delivery level.
As a result of these broad rec

ommendations state and federal
governments agencies and health
care institutions were given notice
about the increased focus on the
prevention of medical errors and
consequently the improved safety
of the patient receiving treatment.
During the 5 years following the
IOM (1999) report progress began
to be made.
In 2001 the U.S. Congress ap

propriated an annual budget of $50
million for patient safety research
(Leape & Berwick 2005). From
this appropriation the Agency for
Healthcare Research and Quality
(AHRQ) was codified as the federal
agency to oversee patient safety and
its improvement (Leape & Berwick
2005). AHRQ became an important
player in the new patient safety
movement by evaluating health care
practices to determine effectiveness
educating health care institutions
about how to best report errors and
adverse events and creating a road

map of evidence-based best practices
(Leape & Berwick 2005).
Using the roadmap created
by AHRQ the National Qual

ity Forum (NQF) (2007) created a
list of 27 serious reportable events
also referred to as
never events

which were offered as the basis
for a potential national reporting
system chronicling patient safety.
The serious reportable events may
be divided into six separate cat

egories including surgical events
product or device events patient
protection events care management
events environmental events and
criminal events (NQF 2007). For
the purposes of this article however
the individual events will not be dis

cussed as the focus is to remain on
the implementation and evolution of
patient safety standards.
In 2005 the American Medi

cal Association (AMA) released
a report by Leape and Berwick
detailing the effects of the origi

nal IOM publication. The AMA
report while admitting there had
been little measurable effect after
the release of the IOM report and
that no comprehensive nationwide
system for monitoring had been
put into existence discussed how
the focus of patient care had shifted
from fixing blame to implementing a
culture of safety (Leape & Berwick
2005). This alone can be considered
an impressive feat in todays increas

ingly litigious society. Furthermore
Leape and Berwick (2005) identified
the four areas the health care system
needed to advance in the following 5
years to facilitate the transition to a
patient safety focus.
First Leape and Berwick (2005)
recommended the implementation
of electronic medical records. It is
argued that this implementation al

though a substantial initial cost will
save the facility and pay for itself
due to the decrease in charges of ad