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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

In the November 25 issue of the ARCHIVES, Rothschild et al¹ provide additional evidence that substantial downstream costs—specifically those of defending and settling malpractice claims—are associated with patient safety violations. While the argument is commendable, and one we have made before,^2-3 it may fall on deaf administrative ears within health care settings for 3 reasons.

First, although the settlement costs associated with malpractice claims sound high—$19 million for agencies covered by the Controlled Risk Insurance Company over a 10-year period, $27 million for adverse drug event claims, and $556 million for all malpractice claims in the Department of Veterans Affairs (VA) during approximately the same time²—those costs are trivial in the context of the overall budget. In the 1990s, direct payments approximated 0.22% of the VA health care delivery budget for all claims and 0.01% for adverse drug event claims.

Second, there are substantial time delays between incident and . . . [Full Text of this Article]