Medical errors and patient safety issues remain a significant problem for the healthcare industry in the United States. The Institute of Medicine report To Err is Human reported that there were as many as 98,000 deaths per year due to medical error as of 1999. Many authors and government officials believe that the first step on the path to improvement in patient safety is more comprehensive collection and analysis of patient safety events. The belief is that this will enable safety improvements based on data showing the nature and frequency of events that occur, and the effectiveness of interventions. This systematization of healthcare practice can be a step in the right direction toward a value based, safety conscious and effective healthcare system. To help standardize this reporting and analysis, AHRQ created Common Formats for Patient Safety data collection and reporting. This manuscript describes the development of patient safety reporting and learning through the Patient Safety Organizations (PSO)s and the Common Formats and gives readers an overview of how the system is expected to function and the breadth of development of the Common Formats to date.

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Each year, the American College of Medical Quality (ACMQ) has held its traditional Quality Institute at the Annual Meeting. Over the past 5 years, the nature and format of the Quality Institute has evolved into one of the best attended and highly rated sessions. The Annual Meeting Committee has supported the move away from passive lecturing to a lively, interactive, and timely case study format that involves negotiation and problem solving within small groups of participants. The Case Study method has evolved over the past 30 years as a very effective and proven learning method that is now used widely in business schools and other post-graduate degree programs.The Institute has attracted highly regarded national expert faculty, who provide firm and factual foundations for small group learning. Some of our guest faculty have included nationally recognized quality leaders, Drs