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an expectation of perfection and attributes errors to carelessness or incompetence. Liability concerns discourage the surfacing of errors and communication about how to correct them. The lack of explicit and consistent standards for patient safety creates gaps in licensing and accreditation and lets health care organizations function without some of the basic safety systems in place. The lack of any agency or organization with primary responsibility for patient safety prevents the dissemination of any cohesive message about patient safety. Given the gaps in the external environment, it should come as no surprise that the health care delivery system is not as responsive as it could be to concerns about patient safety. The external environment is not creating any requirement or demand for the delivery system to reduce medical errors and improve the safety of patients.

Chapter 3, Why Do Errors Happen?, offers a discussion of several concepts in patient safety, including a number of definitions for terms used throughout this report. The chapter describes leading theory on why accidents happen and the types of errors that occur. It also explores why some systems are safer than others and the contribution of human factors principles to designing safer systems.

Chapters 4 through 8 of the report lay out a set of actions that the external environment can take to increase attention by the delivery system to issues of patient safety. They also identify a set of actions that the delivery system can pursue in response. The combination of proposed strategies seeks to build a national focus on patient safety, make more and better information available, set explicit standards for patient safety, and identify how health care organizations can put safety systems into practice.

Chapter 4, Building Leadership and Knowledge to Improve Patient Safety, discusses the need for a focal point for patient safety. The lack of a clear focal point makes it difficult to define priorities, call for action where needed, or produce a consistent message about safety. Other high-risk industries can identify an agency or organization with accountability for monitoring and communicating about safety problems. No such focal point exists in health care. The chapter discusses the role of national leadership to set aims and to track progress over time in achieving these aims, the need to develop and fund a safety agenda, and approaches for improving dissemination and outreach about safety to the marketplace and to regulators and policy makers.

Chapter 5, Error Reporting Systems, discusses reporting systems as one means for obtaining information about medical errors. A number of public and private reporting systems currently exist, some focused on very specific

Front Matter (R1-R24)

Executive Summary (1-16)

1 A Comprehensive Approach to Improving Patient Safety (17-25)

2 Errors in Health Care: A Leading Cause of Death and Injury (26-48)

3 Why Do Errors Happen? (49-68)

4 Building Leadership and Knowledge for Patient Safety (69-85)

5 Error Reporting Systems (86-108)

6 Protecting Voluntary Reporting Systems from Legal Discovery (109-131)

7 Setting Performance Standards and Expectations for Patient Safety (132-154)

8 Creating Safety Systems in Health Care Organizations (155-204)

A Background and Methodology (205-209)

B Glossary and Acronyms (210-214)

C Literature Summary (215-253)

D Characteristics of State Adverse Event Reporting Systems (254-265)

E Safety Activities in Health Care Organizations (266-272)

Index (273-287)