The committee believes a key step in improving the safety of the medication-use process is establishing a strong patient–provider partnership. Chapter 4 provides guidance on ways for both patient and the provider to strengthen this partnership. In addition, the chapter recommends ways of improving the information infrastructure available to the patient.

Chapter 5 contains the committee’s recommendations on short- and long-term system changes that health care organizations can make in the medication-use process in three settings—the inpatient, nursing home, and outpatient—and in care transitions.

Pharmaceutical, medical device, and health information technology companies represent the chief product-related industry sectors of the medication-use system. Chapter 6 provides an action agenda for design improvements to the information products and medical devices produced by these industries, focused on improving medication safety.

The committee uncovered enormous gaps in the knowledge base regarding medication errors. In Chapter 7, the committee proposes an applied research agenda for the safe use of medications across all care settings, covering research methodologies, incidence rates, costs of medication errors, reporting systems, and testing of error prevention strategies.

Finally, health care delivery is shaped by legislators, regulators, accreditators, and payers. Chapter 8 proposes ways for these stakeholders to motivate the adoption of practices and technologies that can reduce medication errors, and to ensure that professionals have the competencies required to deliver medications safely.


Berwick DM. 2002. A user’s manual for the IOM’s “Quality Chasm” report. Health Affairs (Millwood) 21(3):80–90.

Christopherson G. 2004. Person-Centered Health. Notes: Draft document provided to IOM staff.

CIHSP (California Institute for Health System Performance). 2001. A Compendium of Suggested Practices for Preventing and Reducing Medication Errors. Sacramento, CA: CIHSP.

IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

Leape LL, Kabcenell A, Berwick DM, Roessner J. 1998. Breakthrough Series Guide: Reducing Adverse Drug Events. Boston, MA: Institute for Healthcare Improvement.

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