There is a scientific discipline called human factors and ergonomics (HF&E) which recognises the absolute certainty that human beings will make mistakes, and so seeks to design working systems and environments that work around our human nature to reduce the risk of error as far as possible.
Many safety-critical industries like aviation have wholeheartedly adopted HF&E engineering to protect their workforce and service-users from errors. When there is a significant event, the immediate assumption is that there must be a fault somewhere in the system that allowed gaps in the layers of error protection to align and allow a mistake to slip through – rather like the holes in layers of swiss cheese suddenly all lining up (get it?!)
Does any of this sound like what happens in the healthcare system? There is some talk of no-blame investigations and developing a culture of protecting whistleblowers. But in the midst of a locum session, where no induction in practice protocols has been made available, trying to see complex patients in 10 minute appointment slots, dealing with missing results and clinic letters and coping with repeated interruptions for queries from practice staff, it feels like primary care is light years behind being an ideal safe environment.