Preface

Although the Institute of Medicine's (IOM) 1999 report, To Err Is Human: Building a Safer Health System, galvanized action to reduce medical errors, there was already an emerging body of knowledge on why errors occur and how to prevent them. One of the clear messages from the IOM report is that the health care system needed to put that knowledge to work to improve patient safety.

Now, 5 years after the release of To Err Is Human, the evidence on preventing medical errors and the harm they can cause has grown dramatically. The bottom line is that while we certainly have made progress over the last 5 years in taking steps to improve patient safety, we have much more to do. The health care system still faces the challenge of ensuring that this knowledge is used every day to improve patient safety.

Advances in Patient Safety: From Research to Implementation is an important step in meeting that challenge. This compendium is the result of an impressive collaboration between the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs. Publication of this compendium is an important component of AHRQ and DoD's ongoing collaboration and our strategic efforts to disseminate and implement information on patient safety.

The 140 articles in the 4-volume set represent the efforts of AHRQ-funded patient safety researchers as well as the patient safety initiatives of other parts of the Federal Government. The articles cover a wide range of research paradigms, clinical settings, and patient populations, and they cover various stages of the research process. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the volumes include a series of articles that address implementation issues and provide useful tools and products that can be used to improve patient safety.

Our hope is that the information and knowledge contained in these volumes will fuel the momentum of efforts to improve patient safety. This publication should give the reader a sense of what has been accomplished in 5 years and what further needs to be accomplished.

It is important to note that while progress has been made over the last 5 years, as evidenced by the contents of these four volumes, not all boats rise evenly with the tide. Some of the findings and tools detailed between these covers can be implemented fairly quickly and yield immediate results. Others beget new questions, raise new issues, and require further exploration. Only by making this information widely available can we answer these questions and resolve these issues so that the American public receives the highest quality, safest health care possible.

Carolyn Clancy, M.D.
Director
Agency for Healthcare Research and Quality

David N. Tornberg, M.D., M.P.H.
Deputy Assistant Secretary for Clinical and Program Policy
Health Affairs
Department of Defense

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