Concern over the levels of patient safety within hospitals was raised following a series of studies showing unacceptable rates (3–17% of admissions) of adverse events (injury to patients). Government health agencies acknowledged that the standard of safety for patients was unacceptable and that healthcare providers would be required to tackle this issue. Other industries, particularly in the more hazardous sectors such as energy production, take a very systematic approach to managing safety. They have realized that human factors play a major contributing role to accident causation, but that this encompasses not just the humans operating the system, but also the humans who are managing the organization. Leape and colleagues [