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Events Leading to Change
The Institute of Medicine (IOM) report by the Committee on the Quality of Health Care in America in 1999 raised the awareness of not only the medical community, but also of government, licensing and accrediting agencies, and the general public. As the response spread nationally to the increasing awareness of the magnitude of the occurrence of medical errors, legislative initiatives began. 15 states, as of spring of 2003, now require the reporting of sentinel events. As previously mentioned, work is in progress to protect facilities from public discovery of reported sentinel events.
The IOM report formalized recommendations for implementing projects and processes to decrease medical error occurrences, and also recommended the establishment of a Center for Patient Safety within the Agency for Healthcare Research and Quality (AHRQ). The IOM’s intent, with these national directives, is to achieve a 50% reduction in preventable medical errors within 5 years.[5] The committee reported a need to inform the general public to help drive improved patient safety changes. The need to increase awareness of the problem, change and improve internal and external systems, and meet the challenge to initiate a non-punitive environment must be met. There is a general consensus that moving from a non-reporting to a reporting environment may initially increase the number of medical errors statistically being reported. This is due to the increased awareness placed on defining system errors, advanced technology picking up previously unnoticed potential errors, and better reporting by staff in a non-punitive environment. However, as system change occurs, the data should show a decline in medical errors as improvements are implemented