Using the AHRQ Patient Safety Indicators (PSIs), this study found excess mortality, length of stay, and hospital costs in all groups with PSIs in Veterans Health Administration facilities. While variability existed across the nine PSIs analyzed, the two associated with greatest excess mortality and costs were postoperative sepsis and respiratory failure. Investigators provide detailed comparisons of their findings to those of a previous study that conducted similar analyses from nonfederal hospitals. The authors advocate that improved measurement of the impact of medical errors provides economic and ethical arguments for increased resources to patient safety improvement initiatives. Both studies mentioned above followed data published from individual institutions (Classen et al and Bates et al) that were among the first to evaluate the costs associated with adverse events.