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How Safe Is Our Health Care System?

What States Can Do to Improve Patient Safety and Reduce Medical Errors

Workshop Brief for State Health Officials

This workshop was designed for senior State policymakers from the executive and legislative branches of government responsible for State health policy. The workshop was held in Boston, Massachusetts, on March 20-22, 2000.

About the Workshop Sponsor.


Health services researchers estimate that between 44,000 and 98,000 Americans die each year as a result of medical errors. If considered in the statistics, errors in patient care would rank number eight among causes of death in the United States. Costs to the Nation of such preventable errors are estimated to be between $17 and $29 billion.

Although most Americans are aware that medical errors occur, the extent of the problem was fully realized by the general public when the Institute of Medicine (IoM) published its December 1999 report entitled, To Err is Human: Building a Safer Health System.

In addition to describing the prevalence and possible causes of medical errors, the IoM report included several recommendations, some of which are directed toward States. One recommendation calls for a nationwide mandatory reporting system that provides for the collection of standardized information by State governments about adverse events that result in death or serious harm. If they are to implement this recommendation, States will need information about how such systems work in other States and how to balance the advantages of such systems in improving accountability and stimulating quality improvement against concerns about disclosure of information and fears that such disclosures will increase malpractice litigation.

The objectives for participants in this workshop included:

  • Understanding the nature and severity of medical errors, their causes and consequences for healthcare quality and costs.
  • Gaining insight into a conceptual framework and systems approach to address issues of patient safety.
  • Identifying what policy and practice levers States can use to prevent medical errors and improve patient safety.
  • Learning how existing State programs that address the IoM recommendations work and how they could be replicated in other States.


Workshop participants included representatives from State executive offices, State legislative offices, offices of the States' attorneys general, State employee health and benefits offices, State departments responsible for healthcare licensure and insurance, public health departments, State Medicaid agencies, national associations representing State officials, State commissions overseeing the quality of healthcare, independent State data and cost commissions, Federal officials for disease control and prevention, and researchers.


Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health Care System. Washington (DC): Institute of Medicine, 2000.

AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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