It has become common knowledge that health care takes place in complex settings that are fraught with the potential for error. More than this, it is becoming a commonplace understanding that error will occur in hospitals, and that some of those errors will inflict harm on patients and their families. The Institute of Medicine report To Err Is Human,1 describes error as involving multiple aspects with the most obvious being the “sharp end”—the individual who erroneously acted or failed to act is at this sharp end and has historically taken the blame for any harm that ensues.

In an effort to expose the full story of error, the Institute of Medicine report emphasizes the importance of latent errors: those system characteristics that not only make errors possible, but in some cases favor and encourage work patterns that inevitably result in mistakes.

Partly due to this attention to the complex...

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