This review discusses the importance of human factors research in reducing adverse events. Drawing from experiences in cardiac surgery, the authors detail the process of capturing and examining various error types. They use case examples to illustrate specific incidents and demonstrate the utility of a systems approach to uncover solutions. The authors also share lessons learned from exploring similar high-complexity industries. They suggest that the profession must better refine methods for prospective analysis of surgical performance and for retrospective analysis of near misses and critical incidents.