This case study highlights some of the challenges in identifying and reporting system failures from the perspective of an experienced critical care nurse and patient safety researcher.

Medical errors are common in intensive care units (ICUs).11,44 Despite the proliferation of safety-and error-reporting systems, a gap in understanding persists between errors and the latent conditions that allow errors to develop.55 

A significant challenge in identifying and analyzing errors is the customary way that they are reported. Errors have traditionally been categorized by using classification systems based on commonly performed tasks and the individuals involved, systems that inadvertently emphasize human error.66 It is now widely recognized that advances in patient safety will require a much broader approach that includes the recognition and reporting of the system failures that result in both...

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