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The Richard & Hinda
Rosenthal Lecture
2011
New Frontiers in Patient Safety
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T HE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the
Governing Board of the National Research Council, whose members are drawn
from the councils of the National Academy of Sciences, the National Academy
of Engineering, and the Institute of Medicine.
Support for this project was provided by the Richard and Hinda Rosenthal
Foundation.
International Standard Book Number-13: 978-0-309-21803-0
International Standard Book Number-10: 0-309-21803-9
Copies of this report are available from the National Academies Press, 500 Fifth
Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202)
334-3313 (in the Washington metropolitan area); Internet, http://www.
nap.edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among
almost all cultures and religions since the beginning of recorded history. The
serpent adopted as a logotype by the Institute of Medicine is a relief carving
from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. The Richard & Hinda
Rosenthal Lecture 2011: New Frontiers in Patient Safety. Washington, DC: The
National Academies Press.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating
society of distinguished scholars engaged in scientific and engineering research,
dedicated to the furtherance of science and technology and to their use for the
general welfare. Upon the authority of the charter granted to it by the Congress
in 1863, the Academy has a mandate that requires it to advise the federal
government on scientific and technical matters. Dr. Ralph J. Cicerone is
president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the
charter of the National Academy of Sciences, as a parallel organization of
outstanding engineers. It is autonomous in its administration and in the selection
of its members, sharing with the National Academy of Sciences the
responsibility for advising the federal government. The National Academy of
Engineering also sponsors engineering programs aimed at meeting national
needs, encourages education and research, and recognizes the superior
achievements of engineers. Dr. Charles M. Vest is president of the National
Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions
in the examination of policy matters pertaining to the health of the public. The
Institute acts under the responsibility given to the National Academy of Sciences
by its congressional charter to be an adviser to the federal government and, upon
its own initiative, to identify issues of medical care, research, and education.
Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of
Sciences in 1916 to associate the broad community of science and technology
with the Academy’s purposes of furthering knowledge and advising the federal
government. Functioning in accordance with general policies determined
by the Academy, the Council has become the principal operating agency
of both the National Academy of Sciences and the National Academy
of Engineering in providing services to the government, the public, and the
scientific and engineering communities. The Council is administered jointly
by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and
Dr. Charles M. Vest are chair and vice chair, respectively, of the National
Research Council.
www.national-academies.org
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Foreword
The Institute of Medicine launched an innovative outreach program
in 1988. Through the generosity of the Richard and Hinda Rosenthal
Foundation, a lecture series was created to bring greater attention to
some of the significant health policy issues facing our nation today. Each
year a major health topic is addressed through a lecture presented by an
expert in the field. The IOM later publishes this lecture for the benefit of
a wider audience.
The Rosenthal Lectures have attracted an enthusiastic following
among health policy researchers and decision makers in Washington,
DC, and across the country. The lectures produce a dynamic and fruitful
dialogue. In this volume, we are proud to present the remarks of the
Secretary of the Department of Health and Human Services, The Honorable
Kathleen Sebelius. Following the Secretary’s remarks, we had an engaging
discussion on “New Frontiers in Patient Safety,” with Dr. Donald Berwick,
Dr. Carolyn Clancy, Dr. Brent James, and Mr. Paul O’Neill.
I would like to thank Katharine Bothner, Bradley Eckert, Jody Evans,
Roger Herdman, Jillian Laffrey, Emily Lenneville, Abbey Meltzer,
Michael Park, Patsy Powell, Sheri Sable, Judy Salerno, Lauren Tobias,
Danielle Turnipseed, and Jordan Wyndelts for skillfully handling the
many details associated with the lecture program and the publication.
v
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vi FOREWORD
In their lifetimes, Richard and Hinda Rosenthal accomplished a great
deal. The Rosenthal Lectures at the Institute of Medicine are among their
enduring legacies, and we are privileged to be the steward of this
important ongoing series.
Harvey V. Fineberg, M.D., Ph.D.
President
Institute of Medicine
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Contents
WELCOME 1
Harvey V. Fineberg
KEYNOTE PRESENTATION 3
The Honorable Kathleen G. Sebelius
Secretary, U.S. Department of Health and Human Services
DISCUSSION 9
Donald M. Berwick
Administrator, Centers for Medicare and Medicaid Services
Carolyn M. Clancy
Director, Agency for Healthcare Research and Quality
Brent C. James
Chief Quality Officer, Intermountain Healthcare
Paul H. O’Neill
Former Secretary, U.S. Department of the Treasury
BIOSKETCHES 33
vii
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