Abstract:absorb and adjust," our hopes for perfect safety record have become replaced with the realization that the Reason's "Swiss cheese" model applies to complex systems as much as it does to relatively simpler situations and events. Our quest continues toward better, safer healthcare systems. It is a life-long quest that increasingly takes on a form of self-discovering, continually improving organizations, rather than a "once-anddone" achievement of the ever-elusive perfection.
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