In order to develop a strategic plan to address patient safety issues, this study sought a national perspective to outline targets for intervention. Using the Delphi method, a structured technique for eliciting group judgments from expert panels, investigators outline nearly 30 barriers to implementing patient safety systems in health care institutions. The top seven barriers are identified, including competition for scare resources and a lack of resources, as an illustration of approaches required to improve safety. The authors advocate for the use of these identified barriers in supporting leadership decisions, both locally and nationally. Although they acknowledge the efforts of individuals and individual institutions, they suggest that success may arise more effectively with broader systemic approaches.