health care units so that care is delivered safely; by creating health care organizations (collections of health care delivery units) that foster safe care, for example, through training for health care workers; and by encouraging health care organizations to deliver safe care by such means as regulatory and fiscal measures. Many of these efforts are long-standing and predate To Err Is Human. Key examples of such efforts are described below.

Helping the Patient Avoid Medication Errors

Since the early 1980s, the People’s Medical Society has developed guidelines to help consumers avoid medication errors in hospitals and at community and mail-order pharmacies (Personal communication, Charles Inlander, March 25, 2005). Medication errors can also take place in the home, and in June 2004, the National Consumers League, jointly with the Food and Drug Administration (FDA), launched Take with Care, a public education campaign addressing the need to be careful when taking over-the-counter (OTC) pain relievers (National Consumers League, 2004).

Organizing Health Care Units to Deliver Care Safely

For more than a decade, many organizations have provided guidance on safe medication practices for health care delivery units. Since 1994 the Institute for Safe Medication Practices has provided guidance on eliminating medication errors through newsletters, journal articles, and communications with health care professionals and regulatory authorities. In 1996 the National Coordinating Council for Medication Error Reduction and Prevention began publishing a series of recommendations on strategies for reducing medication errors (NCCMERP, 2005). Professional organizations have also offered guidance on medication safety. For example, the American Society of Health-System Pharmacists has provided guidance on safe pharmacy practices in hospitals and integrated health systems. Recently, the American Academy of Pediatrics published guidelines on the prevention of medication errors in the pediatric inpatient setting (Stucky et al., 2003).

Following the publication of To Err Is Human, AHRQ funded studies to evaluate best practices. The agency commissioned the Evidence-Based Practice Center of the University of California, San Francisco–Stanford University to evaluate the evidence supporting a long list of proposed safe practices, including many related to medication (Shojania et al., 2001).

In 2003, the National Quality Forum (NQF) identified 30 practices that should be adopted in applicable care settings, including implementing a computerized prescriber order entry system (safe practice 12) (NQF, 2003). In addition, JCAHO has been active in fostering patient safety for many years. In 1995 it implemented a Sentinel Event Policy that encourages



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