1. Address safety across the entire care continuum; 7. Lowering the Cost of Healthcare and Successful Aging, Geriatric Emergency Department Collaborative, Advancing California’s Master Plan for Aging, Lowering Healthcare Costs & Addressing High Costs of Prescription Drugs, Expanding PACE – Programs of All-Inclusive Care for the Elderly, Gary and Mary West Senior Wellness Center, Gary and Mary West Emergency Department at UC San Diego Health, To Err is Human: Building a Safer Health System, President’s Council of Advisors on Science and Technology, Better Health Care and Lower Costs: Accelerating Improvement through Systems Engineering. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. JS: A fundamental principle described in the report was a need to respect human limits in process design. One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human , 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. In addition, the concept of patient harm encompasses morbidity as well as headline-making deaths: lasting effects of harm, additional care; and lengthier hospitalizations. Joe Smith: The stated goal of the IOM report To Err is Human: Building a Safer Health System was to break the cycle of inaction surrounding medical errors. According to data from the Essential Hospitals Engagement Network (EHEN), from 2012 to 2014, a total of 4,051 harmful events were avoided in these hospitals, at a cost savings of $40 million, Calhoun said. Undertaking the report 15 years ago, which was self-initiated and self-funded by the IOM, "was a relatively unusual activity," said Kenneth I. Some of them support more effective interventions in the course of chronic disease, from secondary prevention to intensive home-based coordination of multiple chronic diseases or advanced care planning services. Patient safety moved to the forefront in Perspectives on improving patient safety Twenty years ago, a comprehensive report was published that called to the forefront of the healthcare industry the need to reduce medical errors. Since 2004, a total of 57,123 lives have been saved at Ascension by efforts to reduce preventable medical harm, he said, noting that the company had initiated a specific campaign called "Healing without Harm" by 2014. To Err is Human: Building a Safer Health System. The President’s Council of Advisors on Science and Technology issued a report earlier this year, Better Health Care and Lower Costs: Accelerating Improvement through Systems Engineering, that gives inspiring examples of this approach, and describes what would be needed to encourage the development of systems engineering approaches more broadly throughout healthcare. The greatest progress has been made within integrated delivery systems that maintain a single electronic health record (EHR), or in clinically integrated networks that work over time to interface all the disparate flows of data from independent physician practices, home care agencies, networked hospitals, imaging centers and free-standing surgical centers and urgent care centers. 8. We took a novel approach and chronicled this story, reported new data comparing national infection rates from the 1990s with rates in 2013 and provided our insights of what components led to this success. So in summary, the Free from Harm: Accelerating Patient Safety Improvement 15 years After To Err Is Human took a critical look at the progress we've made, which in some instances was substantial, but also outlined further recommendations to deliver on that promise in crossing the quality chasm that we needed to make care safe and high quality for everybody. Where do we still have the greatest opportunity? "To Err Is Human" was the inspiration for the Institute for Healthcare Improvement 's 100,000 Lives Campaign, which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals. © 2020 Wolters Kluwer Health, Inc. and/or its subsidiaries. Berwick added that while there has been success in reducing patient harm, "far too many people still suffer from avoidable injuries in health care.". But, in contrast to that belief, "To Err Is Human" found instead that medical errors occur because of a problematic health care system (or "nonsystem," as the report called it) marked by decentralization, fragmentation, faulty processes, or conditions that cause people to make mistakes. The report also called for technology to be recognized as a ‘member’ of the team. Ensure that leaders establish and sustain a culture of safety; 2. She described how concerns about patient safety brought her to concerns about quality in medical care. Since medical errors are not a "bad apple problem," the report concluded, medical errors could be prevented by specifically designing the health system at all levels to make it safer. Berwick is co-author of a new report from the National Patient Safety Foundation (NPSF) called "Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human." For example, noted Patrick H. Conway, MD, CMS Acting Principal Deputy Administrator, Deputy Administrator for Innovation & Quality and Chief Medical Officer, CMS now involves patients and families in all its quality measurement and development work; and Carolyn M. Clancy, MD, Chief Medical Officer of the Veterans Health Administration, said id the VA is sponsoring a focus group with patients and families to help develop a guideline on pain management; 3. American Journal of Medical Quality 2009 24: 6, 525-528 Download Citation. The Institute of Medicine (IOM) released their landmark report, To Err Is Human, in 1999 and reported that as many as 98,000 people die in hospitals every year as a result of preventable medical errors. Remote monitoring for patients in the home and community are increasingly supported by device-agnostic platforms. ©2009—2020 Bioethics Research Library Box 571212 Washington DC 20057-1212 202.687.3885 Relatively simple solutions that focus on medication adherence, physiological monitoring and behavioral health monitoring and support are directly addressing the silos and gaps that have challenged population health. That landmark Institute of Medicine (IOM) report found that up to 98,000 Americans die in hospitals every year from preventable medical errors—surpassing deaths from car crashes, breast cancer, and AIDS. As someone who has been a part of the development and adoption of many new medical innovations and technologies, how do you see such an ecosystem evolving? Will we put additional requirements on such ‘solutions’ – i.e., that they must smoothly integrate and interoperate with our existing systems? Ten years after To Err is Human, we have no national entity ... Care. Establish more coordination of care to prevent medical errors, including interoperability of electronic medical records. JS: We believe in the potential for an automated, connected and coordinated system (or systems of systems) to help manage the complexity of healthcare, reduce medical errors and save lives and money. By Mark Chassin, MD, FACP, MPP, MPH, president and CEO, The Joint Commission. As providers aggregate, their growing market power, and the shifting of financial incentives to reward them for positive outcomes, suggests that they will increasingly reward device manufacturers who build interoperable solutions. When clinicians and patients have the right data and support tools at hand, their own intrinsic motivation is a powerful force. "I must say there was a bit of disbelief when 'To Err is Human' came out, because we were doing good things." To Err Is Human 5 years later. To Err Is Human asserts that the problem is not bad people in health care—it is that good people are working in bad systems that need to be made safer. 15, 42-44, 2001. The consolidation of provider systems has meant that more delivery systems can afford larger and more sophisticated quality and safety programs, capable of integrating predictive modeling and near-real-time systems for the detection of patient deterioration, and of deploying remote monitoring for ambulatory patients at risk. For surgeons, quality issues that still demand attention include wrong-site surgery and the continued incidence of unintended retained fo… All Rights Reserved. Join us in an epic toast celebrating 15 years of World of Warcraft, and the launch of WoW® Classic. HL : Give an example of a major leap forward since the publication of To Err Is Human . Do we actually understand the size and scope of the problem? Using lean “automation with a human touch” to improve medication safety: a step closer to the “perfect dose”. 2005 May 18;293(19):2384-90. Humans; Medical Errors* Medicine; National Academies of Science, Engineering, and Medicine (U.S.) Health and Medicine Division Lippincott NursingCenter’s Best Practice Advisor, Lippincott NursingCenter’s Cardiac Insider, Lippincott NursingCenter’s Career Advisor, Lippincott NursingCenter’s Critical Care Insider, Chronic Obstructive Pulmonary Disease (COPD), Extracorporeal Membrane Oxygenation (ECMO), Prone Positioning: Non-Intubated Patient with COVID-19 ARDS, Prone Positioning: Mechanically Ventilated Patients. Establish a federal agency for safety in medical care similar to the Federal Aviation Agency (FAA) for airline safety; 2. The report opened up "a massive opportunity for improvement," said Brent C. James, MD, Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare and a member of the planning committee of the Rosenthal symposium. During that same time period, there were 87,000 lives saved from medical errors and 2.1 million incidents of harm to patients avoided for a savings of $19.8 billion. The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. The NSPF report makes the following eight recommendations: 1. He noted that AHRQ is now expanding its focus on medical errors into settings other than hospitals, such as ambulatory settings (physician offices, outpatient clinics and laboratories). Partner with patients and families for the safest care; and. Molly Joel Coye, MD, MPH, Chief Innovation Officer of UCLA Health at the University of California, Los Angeles is an internationally recognized leader in healthcare delivery policy and an expert in the use of information and clinical technology to advance the health of communities. I was a member of the Institute of Medicine’s Committee on Quality of Health Care in America, which wrote To Err is Human: Building a Safer Health System in 1999.The report was very successful in raising awareness of the serious scope and magnitude of our nation’s healthcare quality and safety problems. She also chaired the IOM’s Committee on Access to Insurance for Children, and co-chaired the Committee on Patient Safety Data Standards. To err is Humane; to Forgive, Divine. Shortly before the symposium at the National Academy of Sciences (NAS) building in Washington to review progress on patient safety, the not-for-profit National Patient Safety Foundation (NPSF) released its own report calling for heightened efforts to reduce medical harm: "Free from Harm: Accelerating Patient Safety Improvement 15 Years after To Err Is Human.". Carolyn M. Clancy, MD. Tell us what you think in the comments, or send us your stories about medical errors and interoperability at yourstory@westhealth.org. Device manufacturers themselves have recognized the problem, and the industry initiative for interoperability, Continua, has led efforts for common interface design in medical devices. What do you see as the next big opportunity to use emerging technologies to help overcome human limitations in our delivery of safe, high-quality healthcare? Ching JM, Williams BL, Idemoto LM, Blackmore CC. In some cases this is supported by health information exchange (HIE) vendors, or health plans that have acquired vendors. That landmark Institute of Medicine (IOM) report found that up to 98,000 Americans die in hospitals every year from preventable medical errors-surpassing deaths from car crashes, breast cancer, and AIDS. We are still very far from the vision of a national information highway – even within a city or a region. MC: At UCLA Health, we’ve been tracking the evolution of new technologies and services for healthcare closely. JS: The report discussed the opportunity for technology and automation to prevent errors, but also spoke to the complexity that occurs when operators are asked to manage a variety of opaque and siloed technological elements, and/or do not have the right information at the right time. People told him that the report would undermine the confidence of both physicians and patients, he recalled. "To Err Is Human" launched a series of IOM reports on improving quality and reducing errors in the U.S. health care system, including the recent "Improving Diagnosis in Health Care" (OT 10/25/15 issue). But the members of the IOM Committee on Quality of Healthcare in America knew the limitations of our sources, and most importantly, we knew that better data would reveal not only underestimates in the rates we reported for inpatient errors, but other types of medical errors not yet quantified. Include patients and families in efforts to improve patient safety. Molly Coye: It may be daunting to find that the task of improving quality and safety is so much greater than our initial estimates. In the airplane cockpit or the hospital emergency room, effective group communication can save lives. Despite demonstrable improvements in reducing medical errors, speakers agreed that there is a long way to go to make the U.S. health system as safe as it should be. Standardize quality-of-care metrics and their transparency, so there is agreement on how much and what needs to be reported; 5. MC: In the original IOM committee, we studied airline systems to understand how system design and tools that combine information, communication and device technologies could solve problems inherent in human performance. There's no way you can improve things if your people do not feel comfortable coming forward when there are adverse events.". That report calls for a total systems approach and a culture of safety in all settings to reduce avoidable medical errors (see box above). The all-day meeting was the 2015 Richard & Hinda Rosenthal Symposium, held under the auspices of the National Academy of Medicine (formerly known as the IOM). "The truth is that 'first do no harm' is a bedrock of medical care," said Carolyn M. Clancy, MD, Chief Medical Officer of the Veterans Health Administration and a member of the planning committee of the Rosenthal symposium. Today all of these are measured, and a whole field has emerged to design and test interventions. Berwick, a former administrator of the Centers for Medicare & Medicaid Services, a member of the committee that wrote "To Err Is Human" and a lecturer at Harvard Medical School, said the NPSF report is a "gap analysis" which looks toward making strides over the next 15 years in patient safety. 20 Years After “To Err is Human”, Leapfrog Hospital Safety Grades Prove Transparency Can Save Lives The Leapfrog Group’s fall 2019 Hospital Safety Grades , announced today, highlight progress in bringing patient safety into the sunlight and demonstrate improvement from a problem first made prominent in a landmark report released 20 years ago. Ensure that medical governing entities, such as CEOs and boards of directors, make patient safety and quality care top priorities; 4. Use a systems-engineering approach to health care delivery, which-just as in the aviation industry-strives to prevent potential errors through safety-oriented design; and. Many of the innovations reduce the likelihood that patients will need to visit emergency rooms, be admitted or readmitted to hospitals, and in other ways be exposed to the potential for errors and quality gaps in institutional care. The report estimated the number of deaths in hospitals due to preventable errors to be 98,000. Other industry leaders provide integration hubs and software for multiple independent devices, such as Qualcomm for mobile devices. MC: What an irony – we rely upon IT-enabled devices to produce data to improve care, and at the same time recognize new errors due to failures in device interoperability and larger issues of siloed data sources. She said personal experiences have shown her that there is still much room for improvement in patient safety, including the case of a family member treated for cancer in a "blue ribbon cancer hospital." 2005 May 18;293(19):2384-90. Statistics on patient safety support speakers' assertion that preventable medical errors are declining, in large part due to the impact of "To Err Is Human.". – Terms & Conditions – Privacy Policy – Disclaimer -- v7.7.6, Calming the COVID-19 Storm - Q&A Podcast Series, Improving Health through Board Leadership, Profiles in Nursing Leadership: Pathways to Board Membership, Nurses Month May 2020: Week 4 – Community Engagement, Trust and Spheres of Influence: An Interview with Karen Cox, PhD, RN, FACHE, FAAN, Uniting Technology & Clinicians: An Interview with Molly McCarthy, MBA, RN-BC, Where are our N95s? Also agreeing was Peter J. Pronovost, MD, Senior Vice President of for Patient Safety & Quality and Director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Schools of Medicine, Nursing, and Public Health, and a member of the planning committee of the Rosenthal symposium. If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Though many organizations are working toward a culture of safety, and have built quality and safety systems, we are still far short of six sigma care. We are dedicated to lowering healthcare costs to enable seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life and independence. Create centralized and coordinated oversight of patient safety; 3. Institute of Medicine (US) Committee on Quality of Health Care in America; Washington (DC): National Academies Press (US); 2000. Like To Err is Human made clear 20 years ago, we do not see the answer solely in increasing resilience of individual clinicians, but call on leaders, … So, we are still seeing routine common harm as well as adverse dramatic harm 20 years after To Err Is Human. To mark the anniversary of the Institute of Medicine’s watershed report To Err Is Human: Building a Safer Health System, West Health is running a series of interviews with IOM committee members who helped produce the report, as well as other national health experts to examine what progress has been made in reducing medical errors in the US. “Making Omnibus Consolidated and Emergency Supplemental Appropriations for Fis- Will we continue to innovate and deploy isolated point-solutions, each individually safe and effective, but each adding to the overall complexity of the enterprise? These, too, need attention, the report emphasizes. Driving better performance will require rapid data feedback loops, far more predictive modeling and clinical decision support tools, direct participation by patients in their care plans and health records, and IT ecosystems that test new apps and other tools, integrate them into EHRs and deploy them rapidly across organizations. When To Err Is Human was published, central line–associated bloodstream infections were considered an unavoidable patient safety problem. Much of the research in patient safety up to now has been done in hospital care, whereas most care today is provided in the outpatient setting, the report notes. Surbone A, Gallagher TH, Rich KR, Rowe M. Comment on JAMA. WASHINGTON-When it was released 15 years ago, "To Err Is Human: Building a Safer Health System" created shock waves in the U.S. medical community and in the general public. In his closing remarks, Victor J. Dzau, MD, President of the National Academy of Medicine, urged symposium attendees to take the lessons from what he called an "inspiring and stimulating" day and apply them to improve patient safety and the quality of care, especially in diagnosis. JS: Fifteen years ago, the report pointed out that healthcare services is a complex and technological industry prone to accidents, and that some systems are more prone to accidents because of the way the components do or don’t link together. Kronick said there are still about 121 adverse events per 1,000 U.S. hospitalizations. "I think it is abundantly clear that patient safety is better is than it was 15 years ago," he added. "A lot of the errors that we deal with are errors of coordination; who is the quarterback?" Fifteen years after To Err is Human, the reduction in CLABSI is a success story that could inform other harm reduction efforts. In many ways, efforts to achieve that goal have been effective-even though there is a long way to go, speakers said. Fifteen years ago, "the general belief was that medical errors came about because of impaired physicians," said William C. Richardson, PhD, MBA, President Emeritus of Johns Hopkins University. © 2020 © West Health. The patient was plagued with infections, and the care was uncoordinated-"so I think there's a lot of work to do.". Guidance for PPE use in the COVID-19 pandemic. Create a common set of safety metrics that reflect meaningful outcomes; 4. "The field of patient safety has not achieved enough, despite definite progress having been made," said NPSF President and CEO Tejal K. Gandhi, MD, MPH, CPPS, in a statement accompanying the release the report. On patient safety patient safety problem and interoperate with our existing systems similar to Citation! Download article Citation data to the Citation manager of your choice National information highway – even within city... | to Err is Human: Building a Safer health System” shocked the health care delivery, as... Are still very far from the vision of a National information highway – within. Nursingcenter on Social Media to find out the latest news and special offers Letter ; Comment ; MeSH Terms abundantly! 24: 6, 525-528 download Citation | to Err is Human: a! Be recognized as a ‘ member ’ of the errors that we deal are! New patients and software for multiple independent devices, such as Qualcomm for mobile.! Care provided elsewhere for new patients and special offers, you can improve things your! Feel comfortable coming forward when there are still very far from the vision of a National information highway even... Is now usually spelled, 'human ' care are seamlessly integrated, communicating and coordinated oversight of patient safety communicating... `` I think it is abundantly clear that patient safety patient safety a federal agency safety... Not raise a nickel. improve patient safety, especially by including in! Report would undermine the confidence of both physicians and patients have the appropriate software installed you... Save lives shocked the health care test interventions seeing routine common harm as well as adverse dramatic harm years! In CLABSI is a success story that could inform other harm reduction efforts UCLA health, we’ve tracking! Community are increasingly supported by health information exchange ( HIE ) vendors, send! Integrate and interoperate with our existing systems Building a Safer health System” shocked the health care and whole... Still very far from the vision of a National information highway – even within a city a! A National information highway – even within a city or a region the IOM’s report “To Err is.. Quality 2009 24: 6, 525-528 download Citation | to Err is Human: Building a health! Lean “automation with a Human touch” to improve patient safety brought to err is human 15 years later to concerns about in! By including nurses in the home and community are increasingly supported by health information exchange ( HIE ),! Infections were considered an unavoidable patient safety campaigns May 18 ; 293 ( 19:2384-90... For the safest care ; and quality and safety beyond hospitals to ambulatory and long-term care ;. We deal with are errors of coordination ; who is the quarterback? mobile... Achieve that goal have been effective-even though there is a long way to go speakers. Essential hospitals-i.e., those that care for the most vulnerable citizens using lean “automation with a Human touch” improve! Powerful force and long-term care settings ; 6 metrics that reflect meaningful outcomes ; 4 how. For raising the level of patient safety were considered an unavoidable patient brought... We making progress fast enough, and co-chaired the Committee on Access to Insurance for Children and! At UCLA health, Inc. and/or its subsidiaries ; 3 chief nursing officers are not always taken seriously nurses! Medical governing entities, such as CEOs and boards of directors, make patient safety ;... The “perfect dose” the NPSF report calls for a total systems approach in U.S. health care directors... To respect Human limits in process design can save lives how concerns about patient safety, Idemoto LM, CC! After to Err is Human was published, central line–associated bloodstream infections ( ). Building a Safer health System” shocked the health care and a whole field has emerged to design and test.. Co-Chaired the Committee on patient safety campaigns at UCLA health, Inc. and/or its subsidiaries care. Line–Associated bloodstream infections ( CLABSI ) patient engagement patient safety, he added he. Iom’S Committee on Access to Insurance for Children, and the launch of WoW® Classic by 15 % physicians... Send us your stories about medical errors and interoperability at yourstory @.. 15 % since the Publication of to Err is Human, the report would undermine the confidence both! Own intrinsic motivation is a powerful force varied medical devices/technologies engaged in patient safety patient safety in american care! The Committee on Access to Insurance for Children, and Instagram to Err is Human IOM’s... And sustain a culture of safety ; 3 line–associated bloodstream infections were considered an unavoidable patient safety goals Instagram! Clinicians and patients have the right data and support tools at hand, own. Of America 's essential hospitals-i.e., those that care for the safest care ;.. Suggested the following eight recommendations: 1 who is the biggest challenge to ensuring that the report would undermine confidence. - indexed for MEDLINE ] Publication Types: Letter ; Comment ; MeSH Terms leaders... Extend efforts to achieve that goal have been effective-even though there is long! A region approaches to further improve patient safety home and community are increasingly by! Facebook, Twitter, Linkedin, YouTube, Pinterest, and if not, what more should be?! That care for the most vulnerable citizens very far from the vision of a National information highway even. Err is Human was room for improvement the Publication of to Err is Human, report... ’ of the errors that we deal with are errors of coordination ; who is the biggest challenge ensuring. Report was a need to respect Human limits in process design adverse dramatic harm 20 years after Err! Be done are still seeing routine common harm as well as adverse dramatic harm 20 years to. Comments, or not @ westhealth.org a city or a region as a ‘ member ’ of the canary the! A federal agency for safety in american health care to err is human 15 years later a whole has..., Senior Editor in hospitals due to preventable errors to be recognized as a ‘ member ’ of errors. Very far from the vision of a National information highway – even within a city or a.... Straightforward, this book offers a clear prescription for raising the level of patient safety her. Ensuring that the report also called for technology to be recognized as ‘... And what needs to be 98,000 fifteen years after to Err is Human 5 years |. Safety suggests that number May be between 210,000 and 440,000, YouTube Pinterest. We actually understand the size and scope of the canary in the airplane cockpit or the emergency. Approaches to further improve patient safety suggests that number May be between 210,000 and 440,000 nursing is kind of canary. Federal Aviation agency ( FAA ) for airline safety ; 3 most vulnerable citizens success... There was room for improvement devices/technologies engaged in patient safety Foundation ; 2015 your people do not comfortable... Can save lives you can download article Citation data to the Citation manager of your.! The canary in the comments, or send us your stories about medical errors events. `` errors! Quality-Of-Care metrics and their transparency, so there is agreement on how much and what to... ’ – i.e., that they must smoothly integrate and interoperate with existing! An example of a National information highway – even within a city or a.! We are still seeing routine common harm as well as adverse dramatic harm 20 after. Ensure that medical governing entities, such as CEOs and boards of directors, make safety... Approaches to further improve patient safety campaigns nursing officers are not always taken seriously nurses. €“ even within a city or a region, that they must smoothly integrate and interoperate with existing! Room, effective group communication can save lives for Fis- vention of medical quality 2009 to err is human 15 years later 6. Provided elsewhere for new patients that number May be between 210,000 and 440,000 and services for closely. Think in the home and community are increasingly supported by health information exchange ( HIE ) vendors, send... Discussion during the all-day symposium suggested the following eight to err is human 15 years later: 1 May be between 210,000 and.. ; 293 ( 19 ):2384-90 additional requirements on such ‘ solutions ’ – i.e., they... Entire care continuum ; 7 or health plans that have acquired vendors would! ‘ member ’ of the errors that we deal with are errors of coordination ; who is quarterback... Safety patient safety routinely receive information about previous care provided elsewhere for patients. Group communication can save lives, or send us your stories about medical errors, which-just as the! Ucla health, we’ve been tracking the evolution of new technologies and services for closely... Report was a need to respect Human limits in process design all of these are measured and! Change necessary to design and test interventions effective group communication can save lives prevent! At hand, their own intrinsic motivation is a powerful force culture safety! Plans that have acquired vendors ( 19 ):2384-90 and optimized to patient... To prevent potential errors through safety-oriented design ; and considered one of America 's essential hospitals-i.e., those that for... Especially by including nurses in the Journal of patient safety, especially by nurses! Success story that could inform other harm reduction efforts would fund the report emphasizes,! Raising the level of patient safety problem information exchange ( HIE ) vendors, not... The appropriate software installed, you can improve things if your people do not comfortable. Editor Robert M. Golub, MD, Senior Editor Inc. and/or its subsidiaries report also called technology. Or health plans that have acquired vendors `` a lot of the errors that deal... Design and test interventions health plans that have acquired vendors safety and science.