CEOs, not frontline staff, are at the root of the hospital industry shortfall in improving patient safety in the 20 years since the problem was highlighted by the landmark study To Err is Human.

Performance measures have evolved in the past 20 years, but quality experts say they still don’t hold the industry accountable.

No one knows how frequently patients experience harm in healthcare settings, though nearly everyone agrees it’s far too common.

Safety experts say the recent deadly problems at top hospitals demonstrate holes in the culture of safety, transparency and measurement of errors.

A safety improvement network for children’s hospitals serves as an example for other emerging collaborations.

The program was established in 2003, and the state is looking to change it since data recently collected may not be helpful.

Patients, families and providers need support after medical errors occur.

In the 20 years since To Err is Human, so far as we can determine, the progress toward truly safer patient care remains frustratingly slow and spotty.

The success that the Institute of Medicine achieved by raising awareness of the seriousness and ubiquity of safety and quality problems has not been matched by our ability to solve them.

Some experts believe that the attention to measurement and pay for performance has obscured more fundamental drivers of quality that would enhance the intrinsic motivation of the human beings on the front lines of care.

Mistakes can be prevented, but that requires admission of guilt and an action plan that sets goals and holds people accountable if they don’t meet them.