tially life-saving treatment was not used when it should have been. Overall, participants in the study had received only 55 percent of recommended care. There was little difference in the proportion of recommended preventive care provided (55 percent), the proportion of recommended acute care provided (54 percent), and the proportion of recommended care for chronic conditions provided (56 percent).

An adverse event results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.1

A cause for additional concern is that errors resulting in adverse events are likely underreported, perhaps by as much as a factor of 20 (Cullen et al., 1995); that is, for every event reported, 20 are not. Such underreporting likely reflects care providers’ fear of blame and retribution through litigation and of losing professional respect, their failure to appreciate the extent of iatrogenic injury, and the burden of reporting.


In response to To Err Is Human and to the ensuing report of the U.S. Department of Health and Human Services’ (DHHS) Quality Interagency Coordination Task Force (Quality Interagency Coordination Task Force, 2000), a major federal initiative was launched to reduce medical errors and improve patient safety. Congress appropriated $50 million in fiscal year 2001 to carry out this initiative and directed the Agency for Healthcare Research and Quality (AHRQ) to establish a Center for Quality Improvement and Patient Safety.

To date, AHRQ has funded more than 90 new grants, contracts, and other activities. These efforts are organized into several areas, including clinical informatics, centers of excellence, developmental centers, dissemination and education, reporting demonstrations, working conditions, and integrated delivery systems research networks. Nearly half of the AHRQ funding, $22.9 million, supports 16 patient safety reporting demonstration projects. These projects were initiated in September 2001 and are all sched-


This definition makes it clear that the potentially avoidable results of an underlying disease or condition, for example, a recurrent myocardial infarction in a patient who was not given a beta-blocker (an error of omission), should be considered an adverse event.

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