Health care is by far the most hazardous industry, accounting for well over a million injuries and at least 180,000 deaths annually in the United States alone. Unlike most industries, the risks of injury are borne not by the enterprise (the hospital), nor by the workers (doctors, nurses, and others) but by a third party, patients. Mechanisms for identifying, measuring and controlling these risks are strikingly primitive. Regulatory control is also strikingly light.

Barriers to improving risk management in health care include lack of clear lines of accountability, a highly varied and specialized work force, inadequate use of information technology, inadequate leadership commitment to safety, and fundamental cultural patterns of blaming and punishment. Fortunately, several large systems are beginning to address these issues with early modest success.