cause versus the critical reality that there is never just one cause to a medical accident, incident, or misadventure.
Although The Joint Commission serves a terrific role in health care, its Sentinel Event database is extremely small compared with the actual incidence of events in America. We need more. The great benefit of an NTSB approach is that it would not require analysis of every healthcare accident; it could address those events that could have the greatest value to the nation. Critics of health care argue that many hospitals maintain risk-management strategies that are really ‘‘malpractice claims management strategies,’’ focused on sequestering information, gagging survivors and surviving families through awards, and burying mistakes that prevent learning moments. A ‘‘Red Cover Report’’ will move us closer to prevention and give meaning to the lives that are lost, which is what most families seek through their grief.