Document Type

Issue Brief

Publication Date



This issue brief looks at the incidence of error in the health care system, opportunities for a systems-based approach to error reduction, and changes needed in health system culture and training. The lessons of human factors research are considered, with examples of their application in the aviation industry. The paper reviews some error-reduction and patient-safety initiatives undertaken by private-sector organizations and by the Veterans Health Administration.


Issue brief no. 740

Open Access



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.