Conclusions

• Analyzing medical error, and making effective systems change is hard work!
  
• Many proposed interventions are “palliative care”
  
• Additional training and scaring people should not be the result of adverse event investigations
• Beware that safety is not always common sense
  
• Human Factors and Safety Engineering helps develop stronger interventions
  
• Better root cause = better interventions
  
• Failure mode and effect analysis can help us prospectively identify and correct potential patient safety hazards