“Most adverse events have their origin in two places:
- the systems we design around the humans
and
-
the choices of humans within those systems
The resulting harm and the human errors (slips, lapses, and mistakes) that may have caused it are really two forms of outcome—outcomes to be monitored, studied, and perhaps grieved. Systems and choices are where the action is, with culture referring to the choices made within the system.
The first origin of adverse events is system design.
