Project Summary: Write a 5-7 page recommendation to senior leadership about steps the organization needs to take to resolve a patient safety issue that occurred. Include an explanation of why it is important to address the issue and the role the patient safety officer will play in helping to resolve the issue. Alarming numbers of unnecessary patient deaths occur in U.S. hospitals and around the world. "Quality and patient safety in health care have been on the forefront of the public's mind since the publication of the Institute of Medicine's (IOM) seminal report, 'To Err Is Human,' in 1999" (Johnson, Haskell, & Barach, 2016, pg. xv). The literature supports revising systems and processes in an effort to narrow the difficult safety and quality gaps. Worldwide, issues of patient safety and patient-centered quality care drive health care reform. Current approaches are not adequate; patients remain at risk for needless harm.