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thirty years building a really souped-up sports car, but barely a dime or a moment making sure it has bumpers, seat belts, and airbags.”When the IOM report was released its numbers were not immediately accepted by the medical community; however, the 98,000 figure has since been widely accepted and is quoted frequently. Then, in 2010, the Department of Health and Human Services’ Office of the Inspector General stated that the deaths of 180,000 Medicare patients alone in a given year could be attributed to “bad hospital care.” In September 2013 a new study in the Journal of Patient Safety argues that “the numbers may be much higher—between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death” (Allen, 2013; James, 2013).Although prior to publication of the IOM report virtually all healthcare organizations engaged in investigations of events that caused harm to patients, few took a systems-based approach to problem solving. The focus was on individuals and mistakes, rather than on the events that combined to cause an incident to occur. “Based on a ‘name and blame’ culture, the emphasis of such investigations was not on prevention, but on punishment” (USDVA, 2013).When To Err is Human was released in 1999, thirteen states were collecting information on medical errors, but by September 2008 this number had increased to twenty-seven. The trend in developing programs has been away from a solely regulatory function toward both regulatory and patient-safety improvement goals. Many states have developed electronic methods for data collection and reporting, and there is a push toward standardization to make data comparisons more meaningful. Many states have adopted the standardized list of twenty-eight reportable events established by the National Quality Forum (NQF), a non-profit focused on systemic healthcare quality improvement. Overall, a persistent problem remains with the under-reporting of events despite statutory measures intended to address the problem (NASHP, 2007; Yale, 2008). Unfortunately, as of November 2009, there were still only 27 states plus the District of Columbia that had “passed legislation or regulation related to hospital reporting of adverse events to a state agency” (NASHP, n.d.), and there is no indication in early 2014 that this number has increased. The Patient Safety Act Traditionally, patient safety improvement efforts have been hampered by fear of discovery, resulting in under-reporting of medical errors and an inability to collect sufficient data for analysis of adverse events. “[I]n response to growing concern about patient safety in the United States, [the] IOM’s report, and AHRQ data,” Congress enacted the Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41) to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients. The act signifies the federal government’s commitment to fostering a culture of safety (AHRQ, 2008a; Howie, 2009). Encourages the development of patient safety organizations (PSOs) that work with clinicians and healthcare organizations to identify, analyze, and reduce the risks and hazards associated with patient care. Fosters a culture of safety by establishing strong federal confidentiality and privilege protections for information assembled and developed by provider organizations, physicians, and other clinicians for deliberation and analysis regarding quality and safety. Speeds the process for identifying the risks and hazards associated with patient care within a protected legal environment (AHRQ, n.d.; PSOFlorida, 2009a) By creating PSOs to collect and analyze confidential information reported by healthcare providers, organizations can identify patterns of failure and propose measures to eliminate patient safety risks. Many states, including Florida, have created PSOs with the goal of improving the safety of healthcare in their states. Additional federal Patient Safety Organization regulations issued by the Department of Health and Human Services (DHHS) in 2008 went into effect on January 19, 2009 (the Patient Safety and Quality Improvement Final Rule [Patient Safety Rule]). “The Patient Safety Rule establishes a