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It is easier to perceive error than to find truth, for the former lies on the surface and is easily seen, while the latter lies in the depth, where few are willing to search for it. (Johann Wolfgang von Goethe, 1749–1832)
Catastrophic incidents usually occur as a result of a sequence of small events that accumulate to create a more serious situation.1 The resilience of healthcare delivery is such that most problems are of little or no consequence to the patient, and it is only in unfortunate situations that these otherwise insignificant problems combine in a discrete time and space to create a catastrophe. In such situations, it is easiest to blame the person making the last mistake than to indentify a sequence of events that came about through deficiencies in the systems of work that predisposed a fatal error. The unhelpful but enduring view, encouraged by the media, many healthcare managers and practitioners and even some safety scientists, is still that those who make such errors were not trying hard enough. Since arguably there is never only one person at fault, blaming individuals does not allow the identification and avoidance of error inducing states before they can cause harm again.2 In constructing a defence against clinical negligence based on the observation that some behaviours are non-conscious and automatic (and thus unavoidable), Toft and Gooderham3 present a legal argument for moving away from blaming care givers at the sharp end towards managerial responsibility for avoiding errors (see page 69). This may reflect an …
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