THERE IS NO longer any question; current state of patient safety is unacceptable and improving patient safety is a national priority. Across healthcare system, attitudes, level of engagement, and body language of those in system have changed. No longer do providers and agencies launch large-scale challenges to number of deaths or incidences from error that are reported in media. Audiences are no longer full of attendees with arms crossed sending message Not about me or my place. seemingly every new study increases rates of error, harm, and near misses and at all levels of healthcare, and in increasingly more organizations, fact that suffering, death, harm, and near misses happen in midst of exceptional care is accepted. Yet even with declaration of patient safety as a priority or its visibility as a hot topic, organizations and individuals still struggle with next steps. They know they have a problem and are asking questions, Now what do What is a balanced program? How much is enough...or too much? I can't do everything, so what should do? What's a proven strategy? Should be focusing at strategic or operational level? Five- and ten-year retrospective studies (Leape and Berwick 2005; Wachter 2004) conducted on patient safety in United States suggest that generally modest structural and process improvements have been realized, but transformational strategic and operational leaps have not been taken to make healthcare industry safer. The journey is too slow. We have learned much and, as a result, gained a growing sense of how little we know. It is increasingly understood that so much more needs to be done, and time to do it is now. The feature articles in this issue of Frontiers of Health Services Management by Bagian and by Winokur and Beauregard draw on experiences of respected leaders and their organizations: Veterans Health Administration (VA) and William Beaumont Hospital, respectively. Their approaches are complimentary, and their articles are not inclusive of all of their on patient safety. Their organizations are not representative of all organizations, and steps they are taking are not only steps toward reducing harm and establishing a culture of patient safety. At same time, these organizations are doing of patient safety leadership pioneers and can inform our personal practice and that of our institutions. Both organizations have built programs that are innovative, thoughtful, focused and comprehensive, and centered on objective measures and improvement. Both have received significant external recognition for their efforts. At same time, suspect, they would describe themselves as having a great deal more to accomplish. Without question, both of these programs demonstrate an absolute commitment to patient safety as a fundamental property of their care system. It is worthwhile to ground this commentary by listing general elements of a culture of safety. Many such lists exist; expanded set that follows is used by this author based on his own experience and that of his organization. It also draws extensively from many others, including original of Ken Kizer and U.S. Department of Veterans Affairs (Kizer 2005). A culture of patient safety is not plug and play, a switch to be turned on. It is a journey that * is based in trust, human rights, and forgiveness; * is patient and family centered; * has a shared vision for quality and safety, with leadership and staff working together in a balanced process that * draws extensively on leadership, and * expects, enables, and supports highest levels of performance from all; * acknowledges high-risk, error-prone nature of healthcare and requirement of ongoing commitment and vigilence to patient safety as the way we do work by * ensuring individual and shared acceptance of responsibility and accountability for safe delivery of quality care, * encouraging and facilitating reporting and open communication about safety concerns in a fair and just environment, * ensuring that organizational structures, processes, goals, and rewards are aligned with improving patient safety, and * putting in place systems to support safe practice, realize synergies, and mitigate failures of teams; * embraces a focused, prioritized, data-driven, systematic approach; * stimulates a continual tension for change; * allows learning from errors and sharing stories of safety; and * recognizes itself as in an ever-evolving transformation. …