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The Institute of Medicine's 1999 report on medical errors galvanized the public and health professionals. Before then, providers, health care organizations, and policymakers lacked the understanding and incentives to generate the changes in culture, systems, training, and technology to improve safety. Since 1999 there has been progress, but it has been insufficient. Stronger regulation has helped, as have some early improvements in information technology and in workforce organization and training. Error-reporting systems have had little impact, and scant progress has been made in improving accountability. Five years after the report's publication, we appear to be at “the end of the beginning.”