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stitute of Medicine (IOM) dramatically exposed the is-sue of patient safety in health care. Stating the obvi-ous—that human beings make errors—but highlighting the theretofore rarely discussed fact that those of us in health care make errors, the report began a quiet rev-olution in the way health care organizations address safety and quality. “To Err is Human ” was followed shortly by a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century ” (2), which set a course to close the gulf between high-quality health care and the care many people receive in practice. Although “To Err is Human ” mentioned diag-nostic error as an issue, neither report devoted sub-stantial analysis to it nor made recommendations re-lated to it. Also surprising is that there has been little
Ball et al. (Mon,) studied this question.