provement undertook its 100,000 Lives Campaign, aimed at fostering the use of safe practices.

Likewise, an article in Health Affairs reviewing the impact of To Err Is Human (Wachter, 2004) noted that the report had led to improved patient safety processes through stronger regulation (for example, expanded patient safety regulation by JCAHO). The article also pointed to the accelerated implementation of clinical information systems that can help reduce medication errors. In addition, progress had been made on workforce issues, particularly in hospitals through the emergence of hospitalists— physicians who coordinate the care of hospitalized patients. Overall, however, the review suggested that much more needed to be done. Examples cited were the limited impact of error reporting systems and scant progress in improving accountability.

The key messages of To Err Is Human were that there are serious problems with the quality of health care delivery; that these problems stem primarily from poor health care delivery systems, not incompetent individuals; and that solving these problems will require fundamental changes in the way care is delivered. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), took up the challenge of suggesting how the health care delivery system should be redesigned. It identified six aims for quality improvement: health care should be safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001).

The Quality Chasm report and the later IOM report, Patient Safety: Achieving a New Standard for Care (IOM, 2004), also emphasized the need for an information infrastructure to support the delivery of quality health care. The latter report called specifically for a national health information infrastructure to provide real-time access to complete patient information and decision-support tools for clinicians and their patients, to capture patient safety information as a by-product of care, and to make it possible to use this information to design even safer delivery systems (IOM, 2004).

To Err Is Human focused on injuries arising as a direct consequence of treatment, that is, errors of commission, such as prescribing a medication that has harmful interactions with another medication the patient is taking. Patient Safety focused not only on those errors, but also errors of omission, such as failing to prescribe a medication from which the patient would likely have benefited. Box 1-1 portrays in stark terms an example of the failure of the care delivery system to catch and mitigate a medication error and the tragic outcome that resulted.

MEDICATION ERRORS: THE MAGNITUDE OF THE CHALLENGE

Regardless of whether one considers errors of commission or omission, error rates for various steps in the medication-use process, adverse drug



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