Perfect Is Possible; Pilot Projects at Hundreds of Hospitals around the Country Prove That Medical Error Rates Can Be Reduced to Zero

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Byline: Donald M. Berwick, M.D., and Lucian L. Leape, M.D. (Berwick and Leape are members of the Harvard faculty. Berwick is CEO of the Institute for Healthcare Improvement (IHI), and Leape is Adjunct Professor of Health Policy at the Harvard School of Public Health. For health information from Harvard, go to

When defects are common, they can feel normal--inevitable. Instead of trying to fix them, people accept them. For a lot that is wrong with health care today, that is exactly the situation--even though the Institute of Medicine reports that as many as 100,000 people die each year in hospitals from avoidable errors. These errors aren't invisible. Many nurses, doctors, patients and families are all too familiar with what went wrong in care despite the best efforts of the clinicians. But if completely preventing errors seems a hopeless task, why even try?

Recent experience--at first from just a handful of hospitals, but now from hundreds--shows that this pessimism is unfounded. Many kinds of errors can be completely eliminated; "zero defects" is possible. Some hospitals are, for example, achieving once impossible success at eliminating certain kinds of infections and medication errors. There is no reason these successes can't be widely replicated, maybe everywhere.

In 2000, the Robert Wood Johnson Foundation, in cooperation with the Institute for Healthcare Improvement (IHI), challenged hospitals to apply for grants to help them "pursue perfection" in their safety, reliability, patient focus, waiting times and efficiency. More than 200 hospitals applied; seven were chosen as grantees in what became the Pursuing Perfection Project. After five years, each was still far from "perfect," but their achievements clearly raised the bar for all U.S. hospitals.

Two of the grantees--Hackensack University Hospital in New Jersey and McLeod Regional Medical Center in Florence, S.C.--used strict protocols and guidelines and automated systems to ensure that nearly 100 percent of all heart-attack patients received needed medications, driving heart-attack death rates down below 5 percent, compared with the U.S. average for Medicare patients of 10 percent. Cincinnati Children's Hospital Medical Center revolutionized its approach to children with cystic fibrosis and diabetes by giving patients and families much more power to make decisions about their own care, such as adjusting their own medications or creating their own schedules for therapy visits and treatments in the hospital. Complications dropped by 30 to 50 percent.

In Whatcom County, Wash., St. Joseph Hospital used "nurse navigator" coaches (to help coordinate information and plans among physicians and institutions) and a patient-controlled personal health record called the Shared Care Plan for chronically ill patients that defined specific goals and plans that every doctor and nurse involved would abide by. These measures reduced expenses for emergency visits and hospital admissions by an average of $3,000 per patient per year by keeping patients healthy at home. HealthPartners, an integrated-care system in Minneapolis, cut re-admission rates for congestive-heart- failure patients in half by making absolutely sure that medications were correctly prescribed and fully understood by patients every time.

Encouraged by the success of the Pursuing Perfection Project and published scientific studies, the IHI launched the 100,000 Lives Campaign in December 2004 to enlist at least 2,000 U.S. hospitals in an effort to prevent needless in-patient deaths by implementing six proven patient-safety practices that could save an estimated 100,000 lives over 18 months.

What were the practices? Nurses and other hospital workers could call Rapid Response Teams on an emergency basis when they become worried about a patient, instead of waiting for the patient to have a cardiac arrest. …