Compelling features of a safe medication-use system

Abstract

In 1999, the Institute of Medicine (IOM) published the incisive report “To Err Is Human: Building a Safer Health System.”1 This critique was followed by two other IOM reports: “Crossing the Quality Chasm: A New Health System for the 21st Century” in 20012 and “Patient Safety: Achieving a New Standard for Care” in 2004.3 Between the latter reports, Berwick,4 of the National Patient Safety Foundation, authored an inspiring book, Escape Fire: Designs for the Future of Health Care. However, a 2004 national survey of consumers’ experiences with patient safety revealed that, despite five years of focused attention on health safety, the American public did not feel safer.5 Nevertheless, in the May 18, 2005, issue of the Journal of the American Medical Association (JAMA), Leape and Berwick6 observed that “the IOM report truly ‘changed the conversation’ to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices.”