ABSTRACT
Ethnographic research can be used to study what happens all of the time rather than what happens rarely by simply observing day-to-day practice in a particular area. Videoing provides an extra pair of eyes and a window into the practices and culture of the team or unit. In theory the term human error relates to how human performance of a specific function might fail to reach its objectives rather than whether the human failed but in practice the term misleads people to focus on the error of the human. It implies that humans can be also fixed in some way; that the error is in some way controllable or a choice. It points to the individual rather than the system in which they work. Once the type of harm is described as a never event, then the goal is for the harm to never happen but because of the inevitability of error in complex adaptive systems they will happen.
