Dr. Berwick is a former board member of NPSF and currently serves as its Distinguished Advisor. Dr. Berwick offered several examples of how his thinking about safety has evolved - things he thought to be correct that he has since found are not so. What we call an error is an adaptive behavior in another context. There's enormous toxicity in hindsight bias. Once the injury has happened, it takes no intelligence whatsoever to find what went wrong.
Safety is a continually emerging property of a complex system.
People figure out the details if you let them. Breaking the rules is the adaptive response of an intelligent workforce involved at the sharp end of health care. Over-specification is a problem in safety. Reporting for measurement contains almost no information. Reporting that loses the 'story' is mostly a waste.