Every system is perfectly designed to give the result it gives.
—Dr. Edward Deming
When a patient is harmed while receiving health care, traditional patient safety management is mainly focused on searching for adverse events, finding failures, investigating reasons, and sucking guilty ones. It should, however, be a reason for having a deeper look at how the system is designed, how the work is organized, what support the personnel at the sharp end is given, and what kind of leadership is mirrored in the current corporate culture.
The question arises whether the management system can contribute to increased patient safety or not. In my opinion, if it can at nuclear plants, then it ...