ABSTRACT
A cornerstone of the emerging ideas about safety in risk-critical industries is an emphasis on the development of ‘learning’ organisations based on systems thinking. Much current rhetoric emphasises the need to take a systems approach to address patient safety, yet these efforts are often still based on the notion of human acts gone wrong, explained, most frequently, as ‘human error’. Perhaps one of the most painful examples of this involved Susan Nelles, a nurse who was accused of killing infants with digoxin at the Hospital for Sick Children in Toronto, in the cardiac intensive care unit. The real ‘culprit’ was in fact the syringes used at the hospital that produced a substance that was read as digoxin by laboratory tests (Bethune, 2011). Clearly, understanding the human role in adverse events is complex as it is only one of many interacting (often surprising) elements in the causal dynamic.
