Patient safety is not a new concept for health care practitioners, but the attention focused on it by the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System galvanized public and media attention as well as policymakers (Kohn, Corrigan, & Donaldson, 2000). While safety issues are not new for most caregivers, knowledge of how mistakes and errors occur has been advanced by studying other high-risk industries, such as aviation, space, and nuclear power, and learning from a special discipline called human factors engineering (Kohn, Corrigan, & Donaldson, 2000).