• organisational failure
• patient safety
• change management

Every healthcare system has its disasters—high profile failures of care in which many patients are harmed, perhaps seriously, and lives are often lost. In the UK such tragic circumstances have come to light with alarming regularity in recent years,¹ and there has been a series of public inquiries into, for example, avoidable deaths in paediatric cardiac surgery in Bristol, negligent clinical practice in gynaecology in Kent, inappropriate post-mortem tissue removal and retention from children in Liverpool and, most recently and horrifically, the murder of over 200 patients in a period of 23 years by a general practitioner in Manchester.² The cumulative effect of this litany of misadventure is hard to judge, but it has certainly contributed to reducing the willingness of the public and the media to place their trust in clinical professionals and healthcare organisations, and has fuelled calls for more regulation and oversight of clinical practice and the performance of healthcare organisations.

Although the anatomy of these disasters is largely clinical—botched surgery, negligent diagnosis or treatment, errors in prescribing or administering drugs, clinical incompetence, and so on—subsequent inquiries and investigations suggest that their pathology is almost always organisational.³ These problems seem to …