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The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.

This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.

This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.

This special issue discusses Canadian patient safety efforts in identifying risks, designing safe systems, implementing solutions, developing learning systems, and understanding legal decision making.

This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.

This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.

This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.

This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.

This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.

This monthly analysis examines recently reported errors in prescribing fentanyl patches, ordering insulin, and administering vincristine.