Organisational sociology has long accepted that mistakes of all kinds are a
common, even normal, part of work. Medical work may be particularly prone
to error because of its complexity and technological sophistication. The re
sults can be tragic for individuals and families. This paper describes four
intrinsic characteristics of organisations that are relevant to the level
of risk and danger in healthcare settings-namely, the division of labour an
d "structural secrecy" in complex organisations; the homophily principle an
d social structural barriers to communication; diffusion of responsibility
and the "problem of many hands"; and environmental or other pressures leadi
ng to goal displacement when organisations take their "eyes off the ball".
The paper argues that each of these four intrinsic characteristics invokes
specific mechanisms that increase danger in healthcare organisations but al
so offer the possibility of devising strategies and behaviours to increase
patient safety. Stated as hypotheses, these ideas could be tested empirical
ly, thus adding to the evidence on which the avoidance of adverse events in
healthcare settings is based and contributing to the development of theory
in this important area.