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Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human
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Report of an Expert Panel Convened by the National Patient Safety Foundation


Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.


With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.


The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.


The report makes eight recommendations:

  1. Ensure that leaders establish and sustain a safety culture
  2. Create centralized and coordinated oversight of patient safety
  3. Create a common set of safety metrics that reflect meaningful outcomes
  4. Increase funding for research in patient safety and implementation science
  5. Address safety across the entire care continuum
  6. Support the health care workforce
  7. Partner with patients and families for the safest care
  8. Ensure that technology is safe and optimized to improve patient safety

Download the report [PDF] >>
Suggested citation: National Patient Safety Foundation. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. National Patient Safety Foundation, Boston, MA; 2015.

El informe en español  |  O relatório em portuguêse  |  Le rapport en français  |  Il rapporto in italiano


Download the Executive Summary >>


Organizations that have endorsed the content of this report >>


Members of the Expert Panel >>



This project was made possible in part through a generous grant from AIG (American International Group, Inc.) in support of the advancement of the patient safety mission. AIG had no influence whatsoever on report direction or its content.

Access the replay of the January 26, 2016, webcast:

Free from Harm: Accelerating Patient Safety Improvement

with Donald Berwick, Kaveh Shojania, and Tejal Gandhi




Download the report [PDF] >>





The State of Patient Safety
Fifteen Years after
To Err Is Human


Eight Recommendations for
Achieving Total Systems Safety

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