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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)