Disappointing, sad, and scary, but not unexpected.  You can’t expect matters of life and death that effect liability, public relations, and profitability to be properly investigated and resolved by the entities directly involved.  When an airplane crashes, the airlines, manufacturers, and pilots union don’t get to run the investigation and choose the results.  Sure they are involved and try to influence the outcome, but an external agency heads the investigation.<p>Medicine needs some sort of non-punitive external investigative agency.  With the scope so much larger than aviation and death often being a normal outcome, how to structure such an agency would be challenging, but I still think it’s the only way to really address the problem.  The same applies for law enforcement and the use of deadly force.  While many of the people involved have the best intentions, the pressures of the organization put undue bias on any internal investigation.<p>It looks like an agency along these lines may have been formed [1], but the ‘At the invitation of healthcare providers’ isn’t good enough.  A quick google search found others pushing along these lines [3], and it’s interesting that they are talking about error being the ‘third leading cause of death’ in 2014.<p>While critics point out that the study may have an overly broad definition of error, it still seems that there is an issue here from anecdotal experience, and that error shouldn’t even be in the top 10.<p>[1] <a href="http:&#x2F;&#x2F;www.prnewswire.com&#x2F;news-releases&#x2F;pso-services-group-launches-national-medical-safety-board---nmsb-165958516.html" rel="nofollow">http:&#x2F;&#x2F;www.prnewswire.com&#x2F;news-releases&#x2F;pso-services-group-l...</a>
[2] <a href="http:&#x2F;&#x2F;www.ntsb.gov&#x2F;Pages&#x2F;default.aspx" rel="nofollow">http:&#x2F;&#x2F;www.ntsb.gov&#x2F;Pages&#x2F;default.aspx</a>
[3] <a href="http:&#x2F;&#x2F;safepatientproject.org&#x2F;press_release&#x2F;patient-safety-advocates-urge-the-creation-of-a-national-patient-safety-board-to-fight-medical-errors" rel="nofollow">http:&#x2F;&#x2F;safepatientproject.org&#x2F;press_release&#x2F;patient-safety-a...</a>