Examine safety engineering systems at the National Aeronautics and Space Administration and the airline industry. Examine human factors, cultures and working environments within the nation's health care system. Examine technology in health care, both as a tool for improving patient safety and as a factor in causing medical errors. Evaluate market-based disincentives, including the increasing cost pressures and administrative burdens on hospitals and physicians. Identify the most effective continuing education alternatives for physicians and nurses to keep current on advances in their professions.
Valid research is critical.
Interventions must be nonpunitive in nature and oriented to learning. Near-misses can be more important than adverse incidents. Confidentiality guarantees needed Robert M. Crane, senior vice president of Kaiser Permanente and director of that HMO's new Institute for Health Policy, led the call for improved confidentiality for private institutions doing health care research. Witnesses agreed that the need for further research must not delay implementation of evidence-based interventions. Speaking on behalf of state medical licensing and disciplinary boards, Federation of State Medical Boards Executive Vice President James R. Winn, MD, called for in-depth analyses of complaints to these agencies.