In the decade since the release of the Institute of Medicine’s landmark report, “To Err is Human: Building a Safer Health System,” a quiet revolution has taken place in health care.

This revolution is quiet because new quality systems seldom get the attention that health technology or medical breakthroughs garner. In fact, they tend to be simple processes that, when implemented correctly, require little cost and are transparent to patients and their families.

The institute’s research found most medical errors are caused by faulty systems, processes and conditions. According to the report, “mistakes can best be prevented by designing the health system at all levels to make it safer — to make it harder for people to do something wrong and easier for them to do it right.”

Missouri’s health care providers have taken a proactive posture in addressing the cause of and solutions to medical errors. Since 1983, Missouri’s quality improvement organization, Primaris, has led efforts to improve care provided to Medicare recipients. In the late 1990s, the Missouri Hospital Association retained a quality professional and organized a statewide task force on health care quality. Hospitals and physicians also were active participants in Gov. Bob Holden’s Missouri Commission on Patient Safety in 2003.

The governor’s commission was the spur behind the formation of the Missouri Center for Patient Safety. Established in 2005, the center provides solutions and resources to improve patient safety and quality. The center is federally certified as a patient safety organization, allowing it to collect and report information about medical errors as it focuses on prevention.

Since 1999, the number of programs designed to improve patient safety and health care quality has grown phenomenally. Many Missouri health care providers have participated in the Institute for Healthcare Improvement’s “100,000 Lives” and “5 Million Lives” campaigns that were national movements focused on preventing death and harm from medical errors.

Error intervention programs such as Missouri’s “Banding Together — For Patient Safety” and the “Missouri Safe Surgery Saves Lives – DASH!” have reduced the potential for human error in patient care. In addition, the “Just Culture Collaborative” in Missouri urges providers to improve processes by encouraging the reporting of risky situations and medical errors rather than assigning blame. Additional information about these programs is available online at www.mocps.org.

The past decade also has brought about an increased commitment from health care providers to report on their performance. In 2004, Missouri’s hospitals published a voluntary report on health care quality, which is now required of all hospitals nationwide. And, since 2006, hospitals have reported cases of hospital-acquired infection to the state.

Last year, the Missouri Hospital Association Board of Trustees endorsed a set of recommended actions in the event of a serious medical error, also known as an “adverse event.” The board recommends hospitals take three actions following a serious adverse event — inform the patient; report the incident to a patient safety organization like the Missouri Center for Patient Safety; and waive payment.

The board’s action represents a commitment to ensure that adverse events do not happen, and, in the rare occasion when they do, to put the patient first. This year, MHA worked with Missouri’s Medicaid program to help implement a new regulation that requires the reporting of certain medical errors to a patient safety organization.

Missouri’s health care providers and patient safety advocates are proud of the efforts achieved thus far. We remain committed to continued progress. The quiet revolution in quality and safety will continue.