Beginnings

Abstract

The To Err is Human report rests upon a series of historical episodes—the early development of safety thinking in healthcare, the evolution of safety thinking in the safety sciences, and accumulating stories of personal suffering and tragedy experiences by patients. Concerns about the safety of healthcare date at least as far back as the Code of Hammurabi. Early efforts at improving safety appeared sporadically in the eighteenth and nineteenth centuries, but these were isolated and not sustained. Malpractice concerns were also entangled with safety, and the first malpractice crisis in the United States came about due to advances, rather than deficiencies, in care. Public and governmental interest in safety more generally developed out of railway accidents in the nineteenth century. Notions of accidents evolved over time, moving from accident proneness to the domino model, to more complex models such as Reason’s Swiss cheese model. Libby Zion's death results in New York state legislation regulating medical trainees’ supervision and duty hours, marking a change from a self-regulating profession to a more typical service industry. Recognition that health professionals involved in adverse events are also, in a sense, victims begins to grow.