Rethinking patient safety: Why is patient safety event identification so challenging in day-to-day operations?

Since the Institute of Medicine's 1999 To Err is Human report, there has been a flurry of safety activity, including, but not limited to, improved voluntary safety reporting culture, standardization of safety practices, introduction of root cause analyses, safety event debriefs, and fortified institutional infrastructure to support safety work. These practices are used to examine failures and identify areas for improvement. Despite the significant prioritization of safety work, there is evidence to suggest that improvements have been minimal. The purpose of this commentary is to highlight three measurement deficiencies that have been largely overlooked but contribute significantly to the measurement challenge. In doing so, we aim to deepen our understanding of the many challenges we face as a safety community, enabling us to make more informed decisions about measurement going forward.