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Patient safety is seen by many in healthcare as a pressing issue, yet achieving patient safety is difficult. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. The human factors approach maintains that the creation of safety cannot be up to a few good doctors or some exceptionally dedicated nurses or technicians. Of course these individuals exist, and they form a fantastic asset to any healthcare system. They may be the champions who push for a preoperative checklist in the hospital, for a time-out, for a new handwashing basin in a smarter place, or for team training. But just building an organizational safety strategy on individual heroes is a bad idea. It is brittle. What if the heroes leave or burn out? What if they do not succeed in overcoming the many institutional obstacles that conspire against their ability to create safety? People in healthcare often think …