Florence Nightingale is the first to use charts and graphs to show the relationship between hygiene and patient outcomes during the Crimean War.
The American College of Surgeons (ACS) developed the first set of hospital standards, which was one page long, and began on-site inspections.
The American College of Surgery and several other physician groups joined to become the Joint Commission for Accreditation of Hospitals (JCAH). The name changed later to JCAHO as the focus became on outpatient settings and is now known as TJC, or The Joint Commission.
The US government institutes the Medicare program to insure those over 65 or with chronic conditions. Medicaid, a similar program run by states for low-income populations, begins a year later.
The Institute of Medicine (IoM) was founded under the National Academy of Sciences to address the concerns of medicine and healthcare. The IoM has now been renamed the National Academy of Medicine (NAM).
The concept of Quality Improvement is more widely introduced in healthcare by Donabedian and others. Diagnostic-Related Groups (DRGs) are instituted in the U.S., which reduces payment to hospitals from Medicare.
Walt Bogdanich in his Great White Lie book exposed many of the failings of our healthcare system that lead to preventable deaths, even care providers’.
Care begins to move out of the hospital and into outpatient settings. Hospital revenue is significantly impacted by DRGs. Nurses are replaced with unlicensed personnel and education programs are cut.
The Institute for Healthcare Improvement was founded.
Nov + Dec 1999
The Institute of Medicine’s “To Err is Human Report” was published and made the front page of the New York Times revealing that an estimated 44,000 to 98,000 Americans were dying in hospitals due to medical errors.
In response to IOM’s report, Congress passed legislation mandating that the Agency for Healthcare Research and Quality (AHRQ) issue annual reports outlining the progress in safer care. Just 60 days after “To Err is Human” was released, AHRQ released “Doing What Counts for Patient Safety”, which outlined strategies to mitigate medical errors.
Josie King passes away due to Sepsis at world-renowned The Johns Hopkins Hospital.
In response to Josie King’s passing, John Hopkins intensive care specialist, Dr. Peter Pronovost, who cared for Josie King, developed a 5-item checklist to reduce central line infections and the infection rate within Johns Hopkins decreased from 11% to 0%.
The U.S. government introduces “Core Measures” requirements for U.S. hospitals: the first publicly reported patient outcome data.
The Joint Commission introduced the “National Patient Safety Goals” program which articulates steps for reducing medical error and is updated on an annual basis.
Institute for Healthcare Improvement (IHI) launched its campaign, titled 100,000 Lives Campaign, to significantly reduced preventable deaths over 18 months. From this initiative, IHI reported 122,000 fewer preventable deaths.
The HCAHPS survey (Hospital Consumer Assessment of Healthcare Providers and Systems) for American hospitals was introduced as the relationship between patient satisfaction and patient safety became evident.
World Health Organization (WHO) launches its first patient safety campaign entitled “Safe Surgery Saves Lives”, aiming to bring together surgical leaders around the world to focus on key topics such as Surgical Site Infection (SSIs), safe anesthesia, and surgical metrics. During this time, the WHO and a team of Harvard scientists developed the “Safe Surgery Checklist” which was broadly distributed and implemented worldwide.
Department of Veteran Affairs (VA) spearheaded a project aimed at reducing MRSA infections, specifically aimed at prevention and contact with patients. The Centers for Disease Control and Prevention (CDC) noted a ⅔ decrease in the amount of MRSA infections in VA hospitals from 2005-2017.
The Association of American Medical Colleges (AAMC) created the Integrating Quality Initiative which focused on emphasizing patient safety in its medical schools and teaching hospitals’ curriculum.
Boston Children’s Hospital launched the I-PASS project to mitigate hand-off communication errors.
Partnership for Patients, a subgroup in the Affordable Care Act (ACA), was created with the mission to reduce Healthcare-associated Infections (HAIs), adverse drug events, and pressure ulcers.
AHRQ created “National Scorecards for Hospital-acquired Conditions”.
The Joint Commission’s Center for Transforming Healthcare conducted an interdisciplinary, 18-month effort to reduce falls and saw a 62% reduction in fall-related injuries in hospitals.
Patient Safety Movement Foundation is founded to bring all stakeholders across the healthcare ecosystem together to work on this global challenge together. The bold mission established was ZERO preventable deaths by 2020.
Ten year anniversary of the National Health Service’s (NHS’s) National Reporting and Learning System, which was established to aggregate incident data.
Patient Safety Collaboratives program was established in the NHS.
John James publishes a new report based upon data from 2008 – 2011, which, unlike the 1999 IOM study, included errors related to missed care and poor communication. This new report estimates that between 250,000 and 400,000 people die each year due to medical error.
“In September 2018, the Secretary of State for Health and Social Care announced there would be a new patient safety strategy, stating that “every patient – whether in hospital, at home, in a General Practitioner (GP) surgery – expects compassionate, effective and safe care.”
In May of 2019 the World Health Assembly votes and establishes World Patient Safety Day which will be celebrated each year on September 17th.
The Patient Safety Movement Foundation officially launched the #uniteforsafecare campaign.
On World Patient Safety Day, the Patient Safety Movement Foundation hosted a virtual event to honor the 200,000+ lives lost every year due to medical harm. Over 50 speakers shared their heart-wrenching and heroic stories of survival and loss as well as their professional and personal experiences that will help educate and inspire you to #uniteforsafecare!
15 passionate patient safety advocates – patients, families and health workers – gathered at Freedom Plaza in Washington, DC just before 10am local time to walk down Pennsylvania Avenue to the Capitol building to bring awareness to patient safety. We kept the gathering small due to the pandemic and practiced safe distancing and masking along the way.
#uniteforsafecare virtual event
The 2nd annual event brought the world together again to unite for safe care, bringing fresh perspectives and new topics to light about how we can exit this pandemic ready to unite for safe care!