The 1999 Institute of Medicine (IOM) report To Err is Human: Building a Safer Health Care System asserted that 44-98,000 Americans died each year as a result of medical errors and estimated the cost of medical errors to be between $17-29 billion annually.1  Although the IOM report touted anesthesiology as an area where “very impressive improvements” in safety had been made, a 2002 Anesthesiology review suggested that perioperative mortality, and anesthesia-related mortality rates, were around one in 500, and one in 13,000, respectively. And more recent studies maintain that administering an anesthetic remains inherently dangerous because co-morbidities once deemed as contraindications are now considered acceptable risk factors. So, anesthesiologists must continue to participate in a patient safety movement that includes development of valid performance metrics, public acknowledgment of performance gaps, implementation of technology to promote safety...

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