Progress is elusive because culture in health care has not changed

Since 2000, when “To Err Is Human” stimulated action to eliminate errors and mitigate the resultant harm in the United States1 and “An Organisation with a Memory” initiated similar efforts in the United Kingdom,2 healthcare systems worldwide have devoted considerable attention to the safety of patients. Yet despite attempts to reduce adverse events through multilevel interventions and information technology, widespread change in the culture of health care remains elusive.

The numbers of affected patients are astounding. In the United Kingdom, adverse events with resultant harm were estimated to occur in some 10% of hospital admissions, equating to more than 850 000 events annually. In the United States, extrapolations based on medical record reviews imply that 44 000-98 000 lives were lost because of medical errors each year. Although some posit that these numbers were inflated, ongoing work indicates that these estimates may be conservative. For example, Davis et al found that 12.9% of hospital admissions in New Zealand were associated with an …