to the underlying processes, and monitor the effectiveness of the changes. although the cause of most sentinel events is human error, changes in organizational systems will reduce the likelihood of human error in the future and protect patients from harm when human error does occur. specific causes of sentinel events and the solutions that hospitals then used successfully to reduce risks are publicized by tjc annually. alerts have included issues as varied as wrong site surgery, restraint deaths, transfusion and medication errors and patient abductions. in 2005, tjc established an international center for patient safety to collaborate with international patient safety organizations to identify, develop and share safety solutions, conduct joint research, and advocate public policy changes. educational materials to help patients prevent medical errors, sentinel event alerts and other resources are provided on the internet. the leapfrog group staggered by increasing health insurance costs, several large us companies met in 1998 to influence quality and affordability. the resulting leapfrog group agreed to base their purchase of health care on principles that "encourage provider quality improvement and consumer involvement". the group was officially launched in november 2000 with the initial focus provided by the 1999 institute of medicine report – reducing preventable medical mistakes (the report recommended that large employers leverage their purchasing power for the quality and safety of health care). the "leapfrog" concept involved large advances stimulated by rewarding hospitals that implement significant improvements (the leapfrog hospital rewards program). the quality practices mandated are computerized physician order entry (cpoe), evidence-based hospital referral, intensive care unit (icu) staffing by physicians experienced in critical care medicine, and a "leapfrog safe practices score", based on the national quality forum endorsed safe practices. additional initiatives now include public reporting of health care quality and outcomes (hospital quality ratings) to influence consumers' choices. leapfrog now includes more than 170 large private and public healthcare purchasers providing health benefits to more than 37 million employees and retirees, funded by the business roundtable, the robert wood johnson foundation and leapfrog members. medication safety officers society the medication safety officers society formerly known as the american society of medication safety officers (asmso) is a not-for-profit association established in 2006 with a mission to advance and encourage excellence in the profession of pharmacy by providing leadership, direction, education and communication among its members, to represent pharmacy in organized healthcare settings and promote the advancement of safe medication use. it was designed for medication safety officers with the goal to provide an open forum for information sharing and collaboration. asmso was acquired by the institute for safe medication practices (ismp) in 2013 and was renamed the medication safety officers society (msos). membership in msos is currently free to all interested parties who register. missouri center for patient safety the missouri center for patient safety (mocps) is a federally designated patient safety organization (pso)fostering change throughout missouri's health care delivery systems and across the continuum of care. it was established by the missouri hospital association (mha), the missouri state medical association (msma) and primaris in response to recommendations from the governor's commission for patient safety. initiatives that are currently the focus of mocps include the people, priorities and learning together (pplt) initiative, which brings together evidence-based practices that have been part of the work of the mocps and missouri hospital association. this approach offers options for hospitals to select components of the initiative to fit their own unique needs for quality and safety efforts, providing options to select components of most value to the individual hospital. in addition to opportunities to learn the comprehensive unit-based safety program (cusp), teamstepps™, just culture, and other processes to improve teamwork and communication, participants may join clinical collaboratives, including the national cusp/stop bsi and cusp/cauti projects focused on prevention of bloodstream infections and catheter-associated bloodstream infections. additional initiatives include the hand hygiene project, prevention of injury from falls, and hospital and medical offices surveys on patient safety. national patient safety foundation in may 2017 the national patient safety foundation and the institute for healthcare improvement (ihi) began working together as one organization. the merged entity is committed to using its combined knowledge and resources to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care. patient safety movement foundation the patient safety movement foundation (psmf) is a commitments-based global non-profit that has a bold goal to achieve zero preventable deaths in hospitals. psmf works with partners in more than 50 countries worldwide. the organization was founded in 2012 by joe kiani and is based in irvine, california. over the last 7 years, psmf has gathered 4,710 hospitals in 46 countries. these hospitals have reported saving more than 90,146 lives through their commitments. most of these commitments align with the psmf's actionable patient safety solutions (apss), a collection of 34 evidence-based best practice documents which can help hospitals get closer to zero preventable in-hospital deaths when implemented in their facilities. psmf also encourages healthcare technology companies to sign their open data pledge, which 90 companies have signed to date. the open data pledge asks any healthcare technology company to share the data their devices and systems generate without knowingly interfering, blocking or charging for that data. this data is critical to the industry's ability to develop accurate algorithms and processes to keep patients from harm. psmf also has more than 60 partnerships with professional societies, associations, other global non-profits and advocacy groups to help get to zero deaths more quickly. psmf also works closely with patients and their families. they're well known for producing short "patient story" videos that use patient voices to tell stories about preventable deaths and harm - all which are disseminated freely online for anyone to use. psmf annually hosts its world safety, science & technology summit, which brings together all stakeholder groups to discuss solutions to the leading challenges hospitals face. at the summit each year, psmf recognizes influential patient safety advocates with its humanitarian awards, given in memory of beau biden and steven moreau. safe care campaign the safe care campaign is a not-for-profit corporation created to help eradicate hospital-acquired infections. its goal is to instigate a national change in ideology and practices within the healthcare environment in regard to hand hygiene, by emphasizing well-established methods proven to result in safer patient care. united states pharmacopeia the united states pharmacopeia (usp) sets official standards for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the united states, but usp standards are also recognized and used in more than 130 other countries. usp operates two programs to promote patient safety. the medication errors reporting program enables healthcare professionals to report medication errors directly to usp. medmarx, an internet-based error and drug reaction reporting program, is designed for use in hospitals. the usp analyzes the data it receives through its reporting programs, develops professional education programs and disseminates alerts related to medication errors. the medmarx report released in 2007 analyzed 11,000 medication errors during surgery in 500 hospitals between 1998 and 2005. the analysis showed that medication errors that happen in the operating room or recovery areas are three times more likely to harm a patient than errors occurring in other types of hospital care. as of 2007, this was the largest known analysis of medical errors related to surgery.