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To Err is Human

From the Institute of Medicine's landmark 1998 report "To Err is Human":

  • The single greatest impediment to error prevention in healthcare is that "we punish people for making mistakes".
  • As a result of a punitive work environment and because hospital personnel (as well as most of the public) tend to regard health care provider errors as evidence of personal carelessness, most hospitals are unaware of the extent of their errors and injuries.
    • Only 2-3% of major errors are reported through hospital event reporting systems. Health care workers often report only what they cannot conceal.