The focus of safety in many industries is centered on preventing error (mistakes). The elimination of error though is a goal that can’t be achieved. The VA Center for Patient Safety has acknowledged as much in their agency vision by recognizing that they will never be able to eliminate all errors. Improvements in safety then must include approaches that buffer the system and environments from these inevitable errors.

The idea that humans cause error shouldn’t be at all surprising. In fact, it should be expected. Any review of near miss or accident reports often find the culprit to be a machine or human error. These reports come after a tremendous push towards safety improvement across all industries. If even following improvements in safety education error persists, what else can be done to improve the safety of our members?

Todd Conklin has discussed in his podcast that systems need to incorporate a capacity to tolerate these inevitable errors. Knowing that errors will happen, we should have systems that prevent these errors from leading to a catastrophic outcome. This approach could be viewed as adding more layers of Swiss cheese to the system.