Front Matter -- Reviewers -- Preface -- Foreword -- Acknowledgments -- Contents -- Executive Summary -- 1 A Comprehensive Approach to Improving Patient Safety -- 2 Errors in Health Care: A Leading Cause of Death and Injury -- 3 Why Do Errors Happen? -- 4 Building Leadership and Knowledge for Patient Safety -- 5 Error Reporting Systems -- 6 Protecting Voluntary Reporting Systems from Legal Discovery -- 7 Setting Performance Standards and Expectations for Patient Safety -- 8 Creating Safety Systems in Health Care Organizations -- A Background and Methodology -- B Glossary and Acronyms -- C Literature Summary -- D Characteristics of State Adverse Event Reporting Systems -- E Safety Activities in Health Care Organizations -- Index.