Individuals vs. systems

Although systems can be designed to improve quality and safety, a disproportionately large number of errors and failures have been shown to be attributable to a small minority of healthcare workers, an example of the Pareto principle, which states that 80% of errors come from 20% of practitioners.

Improvement at an individual level is essentially based on learning, but this is not simply about acquiring knowledge. It also implies an ability to demonstrate the knowledge through the skill of applying this knowledge in practice and then the attitudes that lead to these skills being used consistently in day-to-day practice.