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Sammanfattning

Effective health care depends on the safe and efficient functioning of a tightly coupled multitude of systems, functions, and specialised services. Both theory and practice have demonstrated how safety management that follows events becomes reduced to uncoordinated and fragmentary fire-fighting. This reactive safety management is inadequate. Safety management should be based on an understanding of why everyday performance as a rule goes well rather than on why it occasionally fails, and actively use this to improve the former (safety-II) rather than simply preventing the latter (safety-I).

MeSH