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‘Bad apples’: time to redefine as a type of systems problem?
  1. Kaveh G Shojania1,
  2. Mary Dixon-Woods2
  1. 1Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toranto, Ontario, Canada
  2. 2Department of Health Sciences, University of Leicester, University of Leicester, Leicester, UK
  1. Correspondence to Dr Kaveh Shojania, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Rm H468, Toronto, Ontario, Canada M4N 3M5; kaveh.shojania{at}

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The patient safety movement of the early 21st century rode into town on the ‘systems’ horse. The Institute of Medicine report confidently declared that ‘The problem is not bad people; the problem is that the system needs to be made safer.’1 Recognising humans as inherently fallible, advocates for patient safety proposed that it was wrong to blame individual clinicians for poorly designed systems that were full of error traps.2 Iconic examples—such as administration of vincristine via the wrong route—were used to show how punishing doctors one at a time did nothing to prevent catastrophic errors from recurring.2 ,3 Individual blame was, therefore, deemed the wrong solution to the problem of patient safety; as long as specific individuals were deemed culpable, the significance of other hazards would go unnoticed. The systems approach sought to make better diagnosis and treatment of where the real causes of patient safety problems lay: in the ‘latent conditions’ of healthcare organisations that predisposed to error.4 In order to promote the learning and commitment needed to secure safety, a ‘no-blame’ culture was advocated.5 With the spotlight switched off individuals, the thinking went that healthcare systems could draw on human factors and other approaches to improve safety.

Almost certainly, the focus on systems has been an important countervailing force in correcting the long-standing tendency to mistake design flaws for individual pathologies. There can be no doubting the ongoing need to tackle the multiple deficits in how healthcare systems are designed and organised. Encouraging examples of just how much safety and other aspects of quality can be improved by addressing these problems continue to appear.6–10 Yet, recent years have seen increasing disquiet at how the importance of individual conduct, performance and responsibility was written out of the patient safety story.11 , …

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