Concepts of Quality and Patient Safety – Health System Example

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"Concepts of Quality and Patient Safety" is a wonderful example of a paper on the health system. The report To Err is Human published in 2000 spurred major changes within the health industry. It focused on medical mistakes that led to adverse events, in many cases death. Many of the cases could have been prevented. These mistakes or errors can occur at any level of treatment, from preventative care to diagnosis and treatment. One of the proposed changes was the development of a nationwide mandatory system for reporting, to collect standardized information from hospitals, and eventually, other institutions also (Kohn, Corrigan, Donaldson, McKay, & Pike, 2000).

The idea of this form of the reporting system is to gather and analyze information concerning why mistakes are happening and to identify ways of preventing the same mistakes from happening again in the future. One challenge in instigating this change was identifying the types of mistakes and errors that occur in hospitals and instigating a reporting system that covered these. A second proposed change was the set standards of performance and expectations for organizations involved in health care that put a greater focus on patient safety (Kohn, et al. , 2000).

This change aimed to increase the effort and focus which hospitals and other organizations put into making sure patient safety was not compromised especially through preventable errors. A challenge that this change is the ambiguity in the recommendation, it is difficult to determine what determines success in this case and what process to follow to reach it. By five years after the report, progress was evident, but it was also evident that there were some gaps between what had been proposed and what currently was in effect.

The medical science involved in treating patients had grown significantly, making patient treatment more complex and the types of errors that could occur more varied and more difficult to predict. In addition the public had longer life spans and the population was aging, with a higher than ever proportion of older individuals (Corrigan, 2005). These factors created challenges for many of the changes that were proposed in the original report. For the development of a nationwide mandatory reporting system, there were now many more types of errors that could occur, and besides staff was already struggling to provide care, let alone report any errors at the same time.

Setting standards of performance and expectations were limited by how strained the system was in providing standard care, and there were issues with the organization within hospitals being poor and inadequate. Ten years after the original report substantial progress was seen throughout the healthcare industry, although some gaps remained. The standards associated with error reporting had substantially increased, indicating that the first change I focus on in this paper had been addressed.

In general, hospitals now exhibit a stronger focus on the safety of the patient than when the report was first published in 2000, and the updated report in 2005 (Wachter, 2010).


Corrigan, J. (2005). Crossing the quality chasm. Building a better delivery system: a new engineering/health care partnership.

Kohn, L. T., Corrigan, J., Donaldson, M. S., McKay, T., & Pike, K. (2000). To err is human. Washington DC: National Academy Press 1-20.

Wachter, R. M. (2010). Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs, 29(1), 165.

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