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set the national goals for patient safety, track progress in meeting these goals, and issue an annual report to the President and Congress on patient safety; and

develop knowledge and understanding of errors in health care by developing a research agenda, funding Centers of Excellence, evaluating methods for identifying and preventing errors and funding dissemination and communication activities to improve patient safety.

National goals for safety should be established through a process involving consumers, providers, health care organizations, purchasers, researchers, and others. The goals should also reflect areas that represent opportunities for significant improvement. In carrying out its activities in the areas of research and dissemination, the Center for Patient Safety should collaborate with universities, research centers, and various groups involved in education and dissemination, such as the National Patient Safety Foundation.

The committee believes that initial annual funding of $30 to 35 million for a Center for Patient Safety would be appropriate. This initial funding would permit a center to conduct activities in goal setting, tracking, research and dissemination. Funding should grow over time to at least $100 million, or approximately 1% of the $8.8 billion in health care costs attributable to preventable adverse events (see Chapter 2). This level is modest compared to the resources devoted to other major health issues. The committee believes a 50% reduction in errors over five years is imperative.

Why a Center for Patient Safety is Needed

As discussed in Chapter 2, errors in health care are a leading cause of death and injury. Yet, the American public is seemingly unaware of the problem, and the issue is not getting the attention it should from leaders in the health care industry and the professions. Additionally, the knowledge that has been used in other industries to improve safety is rarely applied in health care. Although more needs to be learned, there are actions that can be taken today to improve safety in health care. Medical products can be designed to be safer in use, jobs can be designed to minimize the likelihood of errors, and much can be done to reduce the complexity of care processes.

Although multiple agencies are concerned with selected issues that influence patient safety, there is no focal point for patient safety in health care today. Public- and private-sector oversight organizations, such as state licen-



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