The interdependency that is built into a modern hospital, our reliance on checklists, hierarchies, consultations, and each other, protects us individually from taking all of the blame when things go wrong. We can and do make mistakes, but in theory someone is there to catch and correct them. In practice, the system of checks and balances can fail at every level, and a low probability event, a succession of unlikely failures, can be set into motion.
