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. The knowledge base for the reduction of medical errors belongs in the public domain. This knowledge should include the results of numerous, local tests of change in processes that affect error rates.