They also add cost, reduce information exchange, produce fear, and cause their own hazards. Achieving error reduction requires a system for achieving error reduction. Creating, tending, and improving such a system is a job for leaders. Error reduction, prevention, and mitigation are managerial tasks. Safety levels are system properties.
Improvement requires aim .
We will reduce medical errors only if organizations and their leaders intend to do so. Improvement requires measurement. We need much better methods and systems for measuring, predicting, and analyzing errors. Measurement systems, to be effective assets for improvement, should exist primarily to gain knowledge, not primarily to administer rewards and punishments. We can learn better together than separately.