One of the principal foundations in medicine "Primum Non Nocere" ("First, do no harm") is inculcated into every medical student and young physician during their early training. Yet, this mantra seems to lose its luster fairly early in a physician's career as cases of adverse events mount in their individual experience. Indeed, weekly morbidity and mortality conferences review these events as a matter of course. Moreover, many physicians, despite great care, engage in preventable serious adverse or sentinel events, and have to deal with the reality of talking to patients or families about an unexpected outcome that could (should) have been avoided. Ten years after the first Institute of Medicine report "To Err Is Human," which reported the astounding number of annual deaths in the United States owing to medical errors, there is evidence that little progress has been made in reducing these events. This lack of progress is striking for 2 reasons. First, the IOM report was widely reported in both the professional journals and lay media, and patient safety is on the radar chart of most care providers, hospital and clinic administrators, and patients. Second, considerable time, money, and effort have been spent on trying to enhance patient safety in most health care environments.
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