The Long Road to Patient Safety: A Status Report on Patient Safety Systems

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This is a review for a study done by Longo, Hewett, Ge and Schubert which helps to assess the status of hospital patient safety systems based on IOM reports as of 2005. [1]

Research question

What is the status of hospital safety systems since the initial Institute of Medicine (IOM) reports on medical errors and quality?


Survey- based study with 6 focus groups conducted in two states—Missouri and Utah. Focus groups identified a list of patient safety systems which should be present in each of the hospitals which were consistent with IOM recommendations in their initial report.


Survey of all acute care hospitals in Missouri and Utah at 2 points in time, in 2002 and 2004, using a 91-item comprehensive questionnaire (n = 126 for survey 1 and n = 128 for survey 2). To assess changes over time, we also studied the cohort of 107 hospitals that responded to both surveys.

Surveys were assessed on 7 different levels:

  1. There has been no activity to initiate/create this policy characteristic.
  2. There has been no activity to implement this policy characteristic.
  3. This policy characteristic has been discussed for possible implementation but not implemented.
  4. This policy characteristic has been partially implemented in some or all areas of the hospital.
  5. This policy characteristic is fully implemented in some areas of the hospital.
  6. This policy characteristic is fully implemented throughout the hospital.
  7. This policy characteristic is fully implemented throughout the hospital and evaluated for


Main results

Self-reported regression in patient safety systems was also found. The following results were listed:

  1. 74% of hospitals reported full implementation of a written patient safety plan
  2. 9% reported no plan
  3. 31.4% reported full implementation of the plan during Survey 2


Development and implementation of patient safety systems is at best modest. The current status of hospital patient safety systems is not close to meeting IOM recommendations. Data are consistent with recent reports that patient safety system progress is slow and is a cause for great concern. Efforts for improvement must be accelerated.


The 1998 Institute of Medicine (IOM) National Roundtable on Health Care Quality and subsequent IOM reports ushered in a period of extensive research about the quality of the US health care system. The IOM reported that “serious and widespread problems occur in small and large communities alike, in all parts of the country, with approximately equal frequency in managed care and fee-for-service care.”

In To Err Is Human, the IOM provided in-depth analyses of a wide range of patient safety problems and underscored the need for improvement. Subsequently, in Crossing the Quality Chasm, the IOM called for “fundamental change . . . to close the quality gap and save lives,” and proposed a national initiative to “provide a strategic direction for redesigning the health care system of the 21st century.” These documents indicate that successful implementation of change in the nation’s overall health care system requires change in specific patient safety systems at the hospital level. Some tools to achieve such a goal include the use of clinical decision systems CDS in electronic medical records which would help guide the many decision processes of practitioners. In addition, optimization in usability to decrease errors and improve efficiency.


  1. . The Long Road to Patient Safety: A Status Report on Patient Safety Systems. Journal of American Medical Informatics Association. 2005; 294(22):2858-2865.