The human factors view of patient safety says that the major source of risk lies not with individual caregivers but with the system surrounding those caregivers: the organization, administration, design, resourcing, and technology of healthcare. The previous chapters have laid out how individual practitioners’ cognitive and coordinative processes of care delivery are enabled and constrained by this larger system. The reconciliation of goal con©icts, the management of fatigue and production pressures, the provision and maintenance of knowledge and skills, the direction of attention in noisy, multitasking environments-all these processes are in large part produced and in©uenced by how care is organized, administrated, and technically supported.