Earlier research on patient safety also focused on errors of commission (e.g., prescribing a medication that has a potentially fatal interaction with another drug the patient is taking). However, errors of omission (e.g., failing to prescribe a medication from which the patient would likely have benefited) may pose an even greater threat to health. On average, patients receive only about 55 percent of those services from which they would likely have benefited (McGlynn et al., 2003).

It is not possible to quantify the full magnitude of the safety challenge with certainty. The health care sector does not routinely identify and collect information on errors. Experts have challenged the estimates of patient harm attributable to errors, as well as the methodologies used to derive them (Brennan, 2000; Hayward and Hofer, 2001; McDonald et al., 2000; Sox and Woloshin, 2000). As substantial evidence about adverse events continues to accumulate in the United States and other countries (Vincent et al., 2001; Wilson et al., 1995), however, there is no doubt that their occurrence is a serious matter warranting attention. The risks to public safety—and the opportunities for large-scale improvements—are sizable.

As concerns about patient safety have grown, the health care sector has looked to other industries that have confronted similar challenges, in particular the airline industry. This industry learned long ago that information and clear communication are critical to the safe navigation of an airplane. To perform their jobs well and guide their planes safely to their destinations, pilots must communicate with the air traffic controller concerning their destinations and current circumstances (e.g., mechanical or other problems), their flight plans, and environmental factors (e.g., weather conditions) that could necessitate a change in course. Information must also pass seamlessly from one controller to another to ensure a safe and smooth journey for planes flying long distances; provide notification of airport delays or closures due to weather conditions; and enable rapid alert and response to an extenuating circumstance, such as a terrorist attack.

Information is as critical to the provision of safe health care—care that is free of errors of both commission and omission—as it is to the safe operation of aircraft. To develop a treatment plan, a doctor must have access to complete patient information (e.g., diagnoses, medications, current test results, and available social supports) and to the most current science base. The doctor and the patient must also be aware of other environmental factors that affect the ability to implement a treatment plan, such as the availability of hospital beds, current waiting times to obtain specific services, and insurance requirements for prior authorization or use of specific providers. Doctors and nurses armed with information on infectious diseases (e.g., in-



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