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With no coordinated reporting and dissemination on error trajectory, health care has lagged behind other high‐risk industries in creating a safety culture. Aviation has focused on safety for more than 50 years, with a significant reduction in fatalities. Health care has adopted and adapted principles and approaches from aviation as well as other high‐risk, high‐reliability organizations that have similar characteristics, such as intermittent, intense tasks that demand exacting responses (Oster and Braaten, 2020; www.ahrq.gov). One central approach is having a reliable reporting system to systematically collect data on sentinel events for review through standardized processes, and systems that can monitor and improve system safety (Vaughn et al., 2019).

High‐risk industries showing dramatic improvements in quality and safety, however, are supported by a designated agency that sets and communicates goals, brings visibility, and systematically collects and analyzes error reports for root cause analysis, such as the Federal Aviation Association and the National Transportation Safety Board, who issue regulations and investigate aviation events. Even though the 2001 IOM report recommended it, health care still lacks a designated safety agency. Numerous agencies promote the safety and quality agenda, but none is a collection point for analyzing safety or quality data with the goal of sharing results widely, such as share safety alerts and best practices for all settings. The Joint Commission does set regulatory standards and the National Patient Safety goals, but not all hospitals subscribe to The Joint Commission. Chapter 2 offers a summary of federal, regulatory, professional, and consumer agencies and organizations with a safety and quality agenda.

Safety science embraces an organizational framework to minimize risk of harm to patients and providers through both system effectiveness and individual performance by applying human factors, discussed more fully in Chapter 8. Safety science builds on Reason’s (2000) human error trajectory, which uses the model of lining up a stick through the holes of Swiss cheese; sometimes redundancies in the system fail, and all the holes line up, allowing errors to happen. Reason’s definition and classification of errors are in Textbox 1.3.

An adverse event is an injury that results from care management and delivery, not from the underlying patient condition or the reason the patient was seeking care. Preventable adverse events are those attributed to any of the various types of error. Diagnostic errors delay diagnosis, prevent use of appropriate tests, or result in failure to act. Treatment errors can occur while administering treatment, such as errors in administering medication, often delaying treatment or contribute to inappropriate care. Other examples are failure to provide prophylactic treatment, inadequate monitoring or follow‐up, failure to communicate, equipment malfunction, or other system failure.

These examples illustrate the inconsistent nomenclature of a long list of terms that make it difficult to consistently report similar events in a central system. Errors can be defined in multiple ways with varied components, making it challenging to replicate how the aviation industry aggregates reports of airline events.