BMJ Qual Saf doi:10.1136/bmjqs-2012-001368
  • Editorial

Deaths due to medical error: jumbo jets or just small propeller planes?

  1. Kaveh G Shojania, Editor
  1. Correspondence to Dr Kaveh G Shojania, Sunnybrook Health Sciences Centre and University of Toronto Centre for Patient Safety, Room H468, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; kaveh.shojania{at}

Medical harm and hospital mortality: some history

The concept of medical harm has existed since antiquity, famously discussed by Hippocrates and passed on in the term ‘iatrogenesis’, from the Greek for ‘originating from a physician’. The influential 9th century Arab physician, al-Ruhāwī, wrote on this topic, and many others acknowledged the problem of medical harm over the centuries. In the 1860s, Oliver Wendell Holmes, Sr, a prominent American physician and popular writer, stated in an address to the Massachusetts Medical Society: “If the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes”. This same decade also saw the first appearance of Florence Nightingale's work with William Farr on hospital mortality reports, drawing attention to the much higher mortality in London hospitals compared with rural ones.1

In the early 20th century, Ernest Codman introduced morbidity and mortality conferences, promoting the idea of systematically monitoring patient outcomes in order to improve quality.2 Formal studies of iatrogenic injury appeared in the 1960s,3–6 and Ivan Illich's indictment of modern medicine in the 1970s7 briefly brought the problem of iatrogenesis to popular attention.

By the 1980s, many individuals had begun to labour in the vineyard of improving healthcare quality, but their efforts produced only sporadic general interest. Even the Harvard Medical Practice Study8 did not generate sustained attention for the problem of medical harm or healthcare quality. Large scale studies began to appear from other countries,9 and the Harvard Medical Practice Study was replicated in Utah and Colorado.10 However, these studies would not have gained much traction were it not for the US Institute of Medicine publication, To Err is Human, in late 1999.11 The committee that produced this report included many individuals …

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