title: An NTSB for health care: learning from innovation: debate and innovate or capitulate.
abstract: BACKGROUND
  Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world. This first part supports the debate for a National Transportation Safety Board (NTSB) for health care, and the second supports more cross-over adoption by hospitals of methods pioneered in aviation.
  
  
  METHODS
  A review of aviation and healthcare leadership best practices and technologies was undertaken through literature review, reporting body research, and interviews of experts in the field of aviation principles applied to medicine. An aviation cross-over inventory and consensus process led to a call for action to address the current crisis of healthcare waste and harm.
  
  
  RESULTS
  The NTSB, an independent agency established by the United States Congress, was developed to investigate all significant transportation accidents to prevent recurrence. Certain NTSB publications known as "Blue Cover Reports" used by pilots and airlines to drive safety provide a model that could be emulated for hospital accidents.
  
  
  CONCLUSIONS
  An NTSB-type organization for health care could greatly improve healthcare safety at low cost and great benefit. A "Red Cover Report" for health care could save lives, save money, and bring value to communities. A call to action is made in this first paper to debate this opportunity for an NTSB for health care. A second follow-on paper is a call to action of healthcare suppliers, providers, and purchasers to reinvigorate their adoption of aviation best practices as the market transitions from a fragmented provider-volume-centered to an integrated patient-value-centered world.
authors.affiliation: Texas Medical Institute of Technology, Austin, Texas 78722, USA. Charles_Denham@tmit1.org
authors.forename: Charles R
authors.initials: CR
authors.lastname: Denham
authors.forename: Chesley B
authors.initials: CB
authors.lastname: Sullenberger
authors.forename: Dennis W
authors.initials: DW
authors.lastname: Quaid
authors.forename: John J
authors.initials: JJ
authors.lastname: Nance
mesh_terms: D000060:Accidents, Aviation / Q000517:prevention & control; D003695:Delivery of Health Care; D004059:Diffusion of Innovation; D055317:Evidence-Based Practice; D006077:Government Agencies; D019300:Medical Errors / Q000517:prevention & control; D061214:Patient Safety; D018570:Risk Assessment; D018581:Technology Transfer; D014481:United States