We found a legal system that was equally flawed. For every negligent claim... for every negligent injury that led to a claim, there were five claims for which there was no injury. This work was published widely and Axelrod intended to make it the basis for legislation in the state, but shortly after the study was completed, he had a tragic accident that led, shortly afterwards, to his death and his successor chose not to introduce the legislation that the governor had originally sought. So, while we published work widely while there were... while there was a lot of public press, the New York Times had headlines at the time that the material was initially released, and subsequently we published extensively in the New England Journal of Medicine, and in two books, the data really seemed to make no impression until, in 2001... when was, when did that study, the [Quality] Chasm report?

[Q] I think the White House event was 2000.

The [Quality] Chasm report?

[Q] And the White House event was 2000 and Clinton was still in office.

Yeah. It was, it was more than 10 years later that the Institute of Medicine published the [Quality] Chasm report in which they indicated that 100,000 people a year die of injuries incurred in hospitals, that figure having been derived from our study, and that figure led, at that time, to more attention, a great deal more attention. By this time Don Berwick was leading a non-profit organization called the Institute for Healthcare Improvement, and was really exerting an enormous effort on improving quality or helping institutions around the country and around the world improve the quality of their practice. Don, two years ago, using that figure of 100,000, enlisted something over 4000 American hospitals to work with the Institute to save the 100,000 lives that were thought to be the result of injury incurred in hospitals, and the results of that effort have been spectacular.