Ironies of improvement: organizational factors undermining resilient performance in healthcare

Pressures for improved safety and performance in healthcare often are addressed by the imposition of tighter control over processes directed at producing "perfect performance of work." A series of near-miss incidents related to a routine hospital procedure demonstrates how these efforts can yield unintended and unappreciated consequences, undermining system resilience and safety despite the best of intentions. Attention to conflicts between goals and tasks across the organization and the role of workers in creating resilience are overlooked as contributors to system safety.