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NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

Support for this project was provided by The National Research Council and The Commonwealth Fund. The views presented in this report are those of the Institute of Medicine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies.

Library of Congress Cataloging-in-Publication Data

To err is human : building a safer health system / Linda T. Kohn, Janet M. Corrigan, and

Molla S. Donaldson, editors.

p. cm

Includes bibliographical references and index.

ISBN 0-309-06837-1

1. Medical errors—Prevention. I. Kohn, Linda T. II. Corrigan, Janet. III.

Donaldson, Molla S.

R729.8.T6 2000

362.1—dc21 99-088993

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Copyright 2000 by the National Academy of Sciences. All rights reserved.

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.