Five system barriers to achieving ultrasafe health care.

This commentary builds on the notion that our health care system requires structured efforts to improve safety and reliability. The authors summarize five primary barriers: accepting limitations on maximum performance, abandoning professional autonomy, transitioning from the "mindset of craftsman to that of an equivalent actor," needing system-level arbitration to optimize safety strategies, and simplifying professional rules and regulations. Each of these barriers is discussed with thoughtful perspective on both the associated historical and current contextual factors. In comparing safety strategies with other industries, a specific health care framework is also offered, raising distinctions that pose unique challenges. The article concludes with graphic presentation of a strategic view of safety in health care and the construct for a two-tiered system in which one system achieves "ultrasafe" status while the other does not at a calculated and accepted risk.