This commentary discusses the progress made since the IOM report by reviewing the context to the patient safety movement, how health care became so unsafe, and what broad categories have played a role in shaping the current patient safety milieu. The author, who also wrote Internal Bleeding, provides a grade for the broad categories impacting safety efforts, which include regulation, error-reporting systems, information technology, the malpractice system, and workforce and training issues. Two similar articles reflected on this 5-year period, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association.