Blame the systems, not the people

The Chicago-based National Patient Safety Foundation’s philosophy is that most errors result from faulty systems rather than human error and that people are in essence set up to make errors for which they are not responsible. An example: An incorrect medication order is given by a resident who has been on duty for 36 hours to a nurse who is just finishing a double shift. Who’s at fault? The exhausted resident and nurse, or the system and process that assigned those work schedules? That is the distinction between a proximal cause and a root cause.