ABSTRACT

People in any job or role are part of a system. A system of processes, practices, policies, technology, structure and culture. Of course, people are also fallible and will make mistakes, but so often the mistakes and failures have their roots in other aspects of the wider system. Perhaps it was a lack of training, or lack of support, or confusing processes or conflicting rules, or not having learned from previous errors, or individuals who are overly stressed, or even the mistakes of others somewhere else in the system.