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Each year in the United States, millions of people visit hospitals, physicians, and other caregivers and receive medical care of superb quality. But that's not the whole story. Some patients’ interactions with the health care system fall short (Institute of Medicine, 1999, 2001).

At the beginning of the twenty-first century, an estimated 32,000 people died in US hospitals each year as a result of preventable medical errors (Zahn and Miller, 2003). In addition, an estimated 57,000 people in the United States died because they were not receiving appropriate health care—in most cases, because common medical conditions such as high blood pressure or elevated cholesterol are not adequately controlled (National Committee for Quality Assurance, 2010). Hospitals vary greatly in their risk-adjusted mortality rates for Medicare patients; for 2000 to 2002, if hospitals with mortality rates higher than expected reduced deaths to the levels that were expected given their patient mix, 17,000 to 21,000 fewer deaths per year would have occurred (Schoen et al, 2006).

Fatal medication errors among outpatients doubled between 1983 and 1993 (Phillips et al, 1998). Prescribing errors occur in 7.6% of outpatient prescriptions (Gandhi et al, 2005), which amounts to 228 million errors in 2004. In 2007, about 25% of elderly patient received high-risk medications (Zhang et al, 2010). Diagnostic error rates are around 10% for a variety of medical conditions (Wachter, 2010). In some primary care practices, patients are not informed about abnormal laboratory results over 20% of the time (Casalino et al, 2009).

Forty-five percent of adults do not receive recommended chronic and preventive care, and 30% seeking care for acute problems receive treatment that is contraindicated (Schuster et al, 1998; McGlynn et al, 2003). Only 50% of people with hypertension are adequately treated (Egan, 2010). Sixty-three percent of people with diabetes are inadequately controlled (Saydah et al, 2004). In many studies, racial and ethnic minority patients experience an inferior quality of care compared with white patients (Agency for Healthcare Research and Quality, 2010). The likelihood of patients being harmed by medical negligence is almost three times as great in hospitals serving largely low-income and minority patients than in hospitals with more affluent populations (Burstin et al, 1993a; Ayanian, 1994; Fiscella et al, 2000). A recent study of multiple quality measures found that the US continues to have serious quality problems and lags behind other developed nations (Schoen et al, 2006).

A prominent Institute of Medicine report (2001) concluded that between what we know and what we do lies not just a gap, but a chasm. Quality problems have been categorized as overuse, underuse, and misuse (Chassin et al, 1998). We will first examine the factors contributing to poor quality and then explore what can ...

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