It has been nearly 10 years since the Institute of Medicine (IOM) published its 1999 landmark report, To Err Is Human: Building a Safer Health System. Although we have made improvements in the safety of the health care system since that time, there is much more work to be done.

In February 2005, the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs collaborated to publish Advances in Patient Safety: From Research to Implementation to help the health care system by providing state-of-science information on preventing medical errors and the harm they can cause. The publication included work by AHRQ-funded patient safety researchers as well as the patient safety initiatives of other components of the Federal Government.

This new publication, Advances in Patient Safety: New Directions and Alternative Approaches builds on and expands the growing body of evidence for reducing medical errors and improving patient safety. It also provides a forum for the airing of new ideas and approaches that are likely to be successful in the future.

The 115 papers distributed across four volumes—Assessment, Culture and Redesign, Performance and Tools, and Technology and Medication Safety—cover a considerable breadth of content dealing with reporting systems, taxonomies and measurement, risk assessment, safety culture and organizational issues, process improvement, system redesign, patient involvement, teamwork, simulation, human factors, tools and practices, health information technology and medication safety.

Advances in Patient Safety: New Directions and Alternative Approaches presents contributions from a wide variety of disciplines and clinical settings—a very promising sign that the development and spread of patient safety initiatives continues to grow.

It is important to note that some of the same issues and areas of research interest as appeared in the 2005 Advances of Patient Safety: From Research to Implementation appear in this Advances as well. Although no one takes pleasure in recognizing that some threats to patient safety are quite resistant to change, these four volumes give testimony to the perseverance and technical skills of our best researchers. They continue to seek answers to the most challenging patient safety questions.

Excellent progress is being made, and many of the papers describe patient safety success stories in a variety of health care settings. Other papers focus on what we still need to accomplish. This is as it should be.

The bottom line is that improving patient safety and reducing medical errors must continue to be an important priority for the Nation and for our health care system. To achieve a safe, high quality health care system, we need dedication, leadership, and the best information available. AHRQ is very pleased to bring you Advances in Patient Safety: New Directions and Alternative Approaches for you to use as a vital tool in meeting that challenge.

Carolyn Clancy, M.D.


Agency for Healthcare Research and Quality