ABSTRACT
Throughout the patient safety movement, health care leaders have consistently referred to the poten tial value of human factors research on human per formance and system failure (Leape, 2004; Leape, Woods, Hatlie, Kizer, Schroeder, & Lundberg 1998). The patient safety movement has been based on three ideas derived from results of research on human expertise (Feltovich, Ford, & Hoffman, 1997), collaborative work (Rasmussen, Brehmer, & Lepat, 1991), and high-reliability organizations (Rochlin, 1999) built up through investments by other industries:
• Adopt a systems approach to understand how breakdowns can occur and how to support decisions in the increasingly com plex worlds of health care,
• Move beyond a culture of blame to create open flow of information and learning about vulnerabilities to failure, and
» Build partnerships across all stakeholders in health care to set aside differences and to make progress on a common overarch ing goal.
