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Patient safety is of great interest to many stakeholders—patients, regulatory and accreditation bodies, hospital and health system administrators, and health care professionals. Interest has expanded since the publication of the Institute of Medicine’s 1999 report on medical errors and measures necessary to ensure a safer health care system. Its subsequent report in 2001 focus on quality with one aim, to avoid injury to patients and redesign health care, so that safety is a property of the system.49,53 A 2006 report focused specifically on reducing medication errors and adverse drug effects.51 These reports and others reveal that medications errors represent up to 25% of all medical errors.55 Many health care institutions address medication safety through their pharmacy and therapeutics (also commonly called drug and formulary), medication safety, patient safety, and quality improvement committees. Table 134–1 shows a timeline of some important developments in medication safety.

TABLE 134–1Critical Events in the Evolution of Medication Safety

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