The Richard & Hinda
Rosenthal Lecture

New Frontiers in Patient Safety


Washington, D.C.

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

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The Richard & Hinda Rosenthal Lecture 2011 New Frontiers in Patient Safety

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T HE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Support for this project was provided by the Richard and Hinda Rosenthal Foundation. International Standard Book Number-13: 978-0-309-21803-0 International Standard Book Number-10: 0-309-21803-9 Copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www. For more information about the Institute of Medicine, visit the IOM home page at: Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. The Richard & Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

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Foreword The Institute of Medicine launched an innovative outreach program in 1988. Through the generosity of the Richard and Hinda Rosenthal Foundation, a lecture series was created to bring greater attention to some of the significant health policy issues facing our nation today. Each year a major health topic is addressed through a lecture presented by an expert in the field. The IOM later publishes this lecture for the benefit of a wider audience. The Rosenthal Lectures have attracted an enthusiastic following among health policy researchers and decision makers in Washington, DC, and across the country. The lectures produce a dynamic and fruitful dialogue. In this volume, we are proud to present the remarks of the Secretary of the Department of Health and Human Services, The Honorable Kathleen Sebelius. Following the Secretary’s remarks, we had an engaging discussion on “New Frontiers in Patient Safety,” with Dr. Donald Berwick, Dr. Carolyn Clancy, Dr. Brent James, and Mr. Paul O’Neill. I would like to thank Katharine Bothner, Bradley Eckert, Jody Evans, Roger Herdman, Jillian Laffrey, Emily Lenneville, Abbey Meltzer, Michael Park, Patsy Powell, Sheri Sable, Judy Salerno, Lauren Tobias, Danielle Turnipseed, and Jordan Wyndelts for skillfully handling the many details associated with the lecture program and the publication. v

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vi FOREWORD In their lifetimes, Richard and Hinda Rosenthal accomplished a great deal. The Rosenthal Lectures at the Institute of Medicine are among their enduring legacies, and we are privileged to be the steward of this important ongoing series. Harvey V. Fineberg, M.D., Ph.D. President Institute of Medicine

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Contents WELCOME 1 Harvey V. Fineberg KEYNOTE PRESENTATION 3 The Honorable Kathleen G. Sebelius Secretary, U.S. Department of Health and Human Services DISCUSSION 9 Donald M. Berwick Administrator, Centers for Medicare and Medicaid Services Carolyn M. Clancy Director, Agency for Healthcare Research and Quality Brent C. James Chief Quality Officer, Intermountain Healthcare Paul H. O’Neill Former Secretary, U.S. Department of the Treasury BIOSKETCHES 33 vii

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