While it is clear that event-reporting systems are now central elements in effective patient safety systems, their growth and implementation have been slow, and their effective use for implementing strategies for safer care has been even slower. In the decade since the report of the Institute of Medicine (IOM) to Err is Human2 released in 1999, and an Organization with a Memory3 published in 2000, consensus has grown that learning from patient safety events is an essential part of creating safer healthcare systems—at both national and local levels.