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| Executive Summary | |
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| A Comprehensive Approach to Improving Patient Safety | |
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| Patient Safety: A Critical Component of Quality | |
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| Organization of the Report | |
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| Errors in Health Care: A Leading Cause of Death and Injury | |
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| Introduction | |
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| How Frequently Do Errors Occur? | |
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| Factors That Contribute to Errors | |
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| The Cost of Errors | |
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| Public Perceptions of Safety | |
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| Why Do Errors Happen? | |
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| Why Do Accidents Happen? | |
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| Are Some Types of Systems More Prone to Accidents? | |
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| Research on Human Factors | |
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| Summary | |
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| Building Leadership and Knowledge for Patient Safety | |
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| Recommendations | |
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| Why a Center for Patient Safety Is Needed | |
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| How Other Industries Have Become Safer | |
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| Options for Establishing a Center for Patient Safety | |
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| Functions of the Center for Patient Safety | |
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| Resources Required for a Center for Patient Safety | |
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| Error Reporting Systems | |
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| Recommendations | |
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| Review of Existing Reporting Systems in Health Care | |
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| Discussion of Committee Recommendations | |
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| Protecting Voluntary Reporting Systems From Legal Discovery | |
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| Recommendation | |
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| Introduction | |
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| The Basic Law of Evidence and Discoverability of Error-Related Information | |
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| Legal Protections Against Discovery of Information About Errors | |
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| Statutory Protections Specific to Particular Reporting Systems | |
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| Practical Protections Against the Discovery of Data on Errors | |
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| Summary | |
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| Setting Performance Standards and Expectations for Patient Safety | |
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| Recommendations | |
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| Current Approaches for Setting Standards in Health Care | |
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| Performance Standards and Expectations for Health Care Organizations | |
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| Standards for Health Professionals | |
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| Standards for Drugs and Devices | |
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| Summary | |
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| Creating Safety Systems in Health Care Organizations | |
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| Recommendations | |
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| Introduction | |
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| Key Safety Design Concepts | |
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| Principles for the Design of Safety Systems in Health Care Organizations | |
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| Medication Safety | |
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| Summary | |
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| Appendixes | |
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| Background and Methodology | |
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| Glossary and Acronyms | |
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| Literature Summary | |
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| Characteristics of State Adverse Event Reporting Systems | |
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| Safety Activities in Health Care Organizations | |
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| Index | |