Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

Medical errors and the quality problems to which they lead harm millions of Americans each year. If we are to reduce errors and improve quality substantially, we must create systems and care processes that anticipate inevitable human errors and either prevent them or compensate for them before they cause harm. Formidable barriers now stand in the way of progress. Success will require a multifaceted strategy, including public education, government investment and regulation, payment system restructuring, and leadership from within the delivery system. C onc er n a b ou t m ed ic al er r or s is running high in the wake of an Institute of Medicine (IOM) report. Print and electronic media have sustained coverage; state and federal lawmakers have debated proposed legislation; and the Clinton administration took executive action to mobilize federal health programs to respond to the problem.1 However, As Lawrence Altman put it in the New York Times, "Doctors have amputated the wrong leg...for centuries."2 Quality has been a major focus of concern in health care for several decades. How should we fit the recent discourse about medical errors into the larger issue of health care quality? How big a problem is the harm done by medical errors? In this paper we explore these questions, consider how health care would have to change for errors to occur far less often, discuss the barriers to such change, and identify five directions for policies that might accelerate it.

National interest in the quality of American health care increased dramatically in 1999. The press, the Institute of Medicine, legislators, physicians, and hospitals joined in a vigorous policy discussion. But a similar debate occurred in 1988, following reports from four public agencies that detailed their concerns about health care quality. In the intervening decade, research has not documented much improvement. In this paper we outline the quality problems in U.S. health care, review some of their most prominent causes, consider the biggest obstacles to bringing about major improvement, and discuss the vital role of leadership in achieving this goal.

Pediatricians believe that all families with guns should receive firearm safety counseling. However, pediatricians significantly underestimate the likelihood of gun ownership by specific families. Parents who own guns indicate that they would acknowledge gun ownership if their pediatrician asked about guns in the home. Therefore, rather than relying on assumptions about whether particular patients seem likely to be gun owners, pediatricians should ask all families whether they own guns.