Complex failures don’t have a single root cause. Complex failures have many causes that are distributed across time, systems, and organizational boundaries, and fixing just one leaves the rest in place.

Your system passed every test. Redundancy was in place. Then something unexpected happened anyway. Resilience Engineering is the framework for building systems that hold up when the unexpected is inevitable.

A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.