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generally defines minimum levels of capability or expected performance. Through some type of monitoring mechanism (e.g., surveillance system, complaint or reporting system, inspections), problems can be identified and corrective action taken to maintain the minimum levels of performance.

However, the committee recognizes that regulation alone will not be sufficient for achieving a significant improvement in patient safety. Careful alignment of regulatory, economic, professional and other incentives in the external environment is critical if significant improvements in safety are to occur. In developing its recommendations, the committee sought a careful balance between the regulatory/legislative influences and the influence of economic and other incentives. The precise balance that will prove most successful in achieving safety improvements is unknown. Ongoing evaluation should assess whether the proper balance has been achieved relative to safety or if refinement is needed.

The committee's strategy for improving patient safety is for the external environment to create sufficient pressure to make errors so costly in terms of ability to conduct business in the marketplace, market share and reputation that the organization must take action. The cost should be high enough that organizations and professionals invest the attention and resources necessary to improve safety. Such external pressures are virtually absent in health care today. The actions of regulatory bodies, group purchasers, consumers and professional groups are all critical to achieving this goal. At the same time, investments in an adequate knowledge base and tools to improve safety are also important to assist health care organizations in responding to this challenge.

Organization of the Report

Following is a brief description of each of the remaining chapters in the report. As a whole, these chapters lay out a rationale for taking strong actions to improve patient safety; a comprehensive strategy for leveraging the actions of regulators, purchasers, consumers, and professionals; and a plan to bolster the knowledge base and tools necessary to improve patient safety.

Chapter 2 of this report, Errors in Health Care: A Leading Cause of Death and Injury, reviews the literature on errors to assess current understanding of the magnitude of the problem and identifies a number of issues that inhibit attention to patient safety. A general lack of information on and awareness of errors in health care by purchasers and consumers makes it impossible for them to demand better care. The culture of medicine creates