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Although Hippocrates said “first, do no harm” over 2000 years ago and many hospitals have long hosted conferences to discuss errors (Morbidity and Mortality, or “M&M,” conferences), until recently medical errors were considered an inevitable by-product of modern medicine or the unfortunate detritus of bad providers. This began to change in late 1999, with the Institute of Medicine's (IOM) publication of To Err is Human: Building a Safer Health System.1 This report, which estimated that 44,000 to 98,000 Americans die each year from medical mistakes, generated tremendous public and media attention, and set the stage for unprecedented efforts to improve patient safety. Of course, these seminal works built on a rich tapestry of inquiry and leadership in the field of patient safety (Appendix III), familiar to a small group of devotees but generally unknown to mainstream providers, administrators, policymakers, and patients.

The IOM death estimate, which was drawn from thousands of chart reviews in New York,2,3 Colorado, and Utah4 in the late 1980s and early 1990s, was followed by studies that showed huge numbers of medication errors, communication problems in intensive care units (ICUs), gaps in the discharge process, retained sponges in the operating room—in short, everywhere one looked there was evidence of major problems in patient safety. Moreover, accompanying this information in the professional literature were scores of dramatic reports in the lay media: errors involving the wrong patient going to a procedure or the wrong limb being operated on, chemotherapy overdoses, botched transplants, patients released from the emergency department (ED) only to die later from myocardial infarction or aortic dissection, and more (Table 1-1).

Table 1-1 Selected Medical Errors that Garnered Extensive Media Attention in the United States*

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