The reported number of WSS cases continues to increase as health care organizations become more transparent to medical error. Many health care organizations, drawing on error-prevention theories and the experience of the aviation industry, recognize that through such transparencies, systems can change and result in better patient outcomes. However, it is unlikely that WSS will fully be reported because of industrywide report cards, fear of litigation, and difference of opinions. Although absolute numbers of WSS may not be striking, the consequences to the patient on whom it occurs are dire.