Commentary

Primum Non Nocere

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References

Read the report (available at www.nap.edu/21794) and lead the charge in your setting. I am interested in how you think this initiative will evolve, and what role you will take in advancing it as a priority in your setting; let me know by writing to NPEditor@frontlinemedcom.com.

REFERENCES
1. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds; Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007:27.
2. Institute for Healthcare Improvement. What happened to Josie? www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx. Accessed October 5, 2015.
3. Andrzejczak OV. “60 Minutes” ace’s death echoes his own investigations. Houston Chronicle. July 30, 2009. www.chron.com/news/article/60-Minutes-ace-s-death-echoes-his-own-1747718.php. Accessed October 5, 2015.
4. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients—results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-376.
6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients—results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324: 377-384.
7. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
8. Balogh EP, Miller BT, Ball JR, eds; Committee on Diagnostic Error in Health Care, Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.

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