U.S. Government Health IT Magazine, July 2007 The U.S. medical system has few peers. With its financial resources, sophisticated diagnostic equipment, pharmaceutical advances and other features, the nation's health care system is world-class. Yet U.S. health care has tended to register an unhealthy number of preventable errors. In its landmark report, "To Err Is Human: Building a Safer Health System," the Institute of Medicine estimated the number of unnecessary mistakes that result in death at about 100,000 annually. In the 1970s, aviation suffered a series of tragic crashes, culminating in the collision of two Boeing 747 airliners that killed 583 people near Spain's Canary Islands. Investigators found that most of the crashes were caused not by catastrophic equipment failure but by poor communication, ineffective leadership, faulty procedures, insufficient standards and flawed decision-making. Warnings that went unrecognized or unheeded often preceded crashes. "There was no system to say, ‘Whoa. Gee, this could happen again. Let's do something about it,'" said Jennifer Baer, administrator of health care quality and patient safety at the University of Texas Medical Branch (UTMB) in Galveston. To protect against those newly identified crash factors, aviation experts worked with NASA and the Federal Aviation Administration to devise crew resource management (CRM), a checklist-based communications system for commercial and military fliers. "It's very clear," Baer said. "There's no room for flying by the seat of your pants." Intrigued by CRM's success in the aviation field, UTMB joined the ranks of health care organizations that have adapted the philosophy to the needs of their community. With the help of a Memphis-based company that offers CRM training to medical organizations, UTMB introduced the program in its operating rooms.