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Fifteen years after To Err is Human: a success story to learn from
  1. Peter J Pronovost1,
  2. James I Cleeman2,
  3. Donald Wright3,
  4. Arjun Srinivasan4
  1. 1Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; Anesthesiology and Critical Care Medicine, Surgery, and Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA
  2. 2Agency for Healthcare Research and Quality, Center for Quality Improvement and Patient Safety, Rockville, Maryland, USA
  3. 3U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Rockville, Maryland, USA
  4. 4Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
  1. Correspondence to Dr Peter J Pronovost, Anesthesiology and Critical Care Medicine, Johns Hopkins University, 750 E. Pratt Street, 15th floor, Baltimore, MD 21202, USA; ppronovo{at}

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Preventable harm is a major cause of preventable death worldwide. In late 1999, the Institute of Medicine (IOM) released To Err is Human,1 a report that riveted the world's attention to between 44 000 and 98 000 patient deaths annually in the USA from medical errors. Progress towards reducing these harms has proven difficult because healthcare lacks robust mechanisms to routinely measure the problem and estimates of the magnitude vary widely. It is hard to gauge safety when healthcare uses multiple different measures for the same harm and provides limited investment in measurement, implementation and applied sciences.

Central line-associated bloodstream infection (CLABSI) provides a notable exception and case study for learning. Over the past 15 years, through the combined and coordinated efforts of many, these infections have been reduced over 80% in intensive care units (ICU), decreasing patient mortality.2 In this essay, we reflect on the journey in preventing these infections and explore how this success can inform and accelerate efforts to reduce other types of preventable harm.

While this paper is a synthesis of past work, what is novel is providing the historical profile of CLABSI, comparing infection rates before and 15 years after the IOM report and offering new insights into what led to the substantial reductions in infections. The journey began in the 1970s when the Centers for Disease Control and Prevention (CDC) began collecting data on ICU CLABSIs. Over the next several decades, the CDC published data on national benchmarks for CLABSI, investigated bloodstream infection outbreaks and published the first Guideline for the Prevention of Intravascular Catheter-Related Infections in 1991. These early efforts brought little change in ICU CLABSI rates throughout the 1990s, with clinicians and policy makers believing infections were inevitable.

Over the last decade, ICU CLABSI rates have dropped throughout the USA (table 1) and …

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