There has been a paradigm shift in terms of thinking about errors. In the aftermath of disasters, the lens of responsibility is being refocused away from people and towards (work) places. Institutions not individuals, processes rather than persons are becoming the focus of investigation. The search for scapegoats is beginning to look crass and ineffective. This is reflected in the formal responses to these events, such as public inquiries, which now routinely focus on system responsibility. Whilst systems analysis has obvious merits it also raises important and unresolved questions. In particular, what are the risks of this shift towards systems thinking? What are the implications for individual professional responsibility? Will the commitment to systems responsibility be meaningful in practice? First, however, we must sketch the contention and connotation of different descriptions of error episodes and appreciate the true toll of the error problem in medicine.
In a recent case in the UK, six men stored their sperm before undergoing chemotherapy treatment for cancer in case they proved to be infertile after the treatment. The sperm was not properly stored and as a result was inadvertently destroyed. The men sued the NHS Trust that stored the sperm and were in the end successful. This paper questions the basis on which the judgement was made and the rationale behind it, namely that the men ‘had ownership’ of the sperm, and that compensation was thus due on the grounds that the men's property had been destroyed.