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IMF-073-01-0001-en	Why does patient safety attribute most adverse events to systems rather than to one careless individual, and why is blame alone insufficient?	Most adverse events arise from interactions among people, tasks, technology, environment, organisation, and patient factors, so blame without system learning leaves the hazards intact.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0002-en	What distinguishes a slip, a lapse, and a mistake?	A slip is an execution failure, often during familiar automatic work; a lapse is a failure of memory; a mistake reflects a flawed rule-based or knowledge-based decision.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0003-en	How does a violation differ from an error, and why does the distinction matter?	An error is failure of a planned action or use of an incorrect plan, whereas a violation is a deliberate departure from a rule; the distinction guides both prevention and accountability.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0004-en	What distinguishes a near miss, a no-harm incident, and an adverse event?	A near miss is intercepted before injury; a no-harm incident reaches the patient without discernible injury; an adverse event causes harm related to care rather than the underlying disease.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0005-en	How does outcome bias distort the judgement of care, and how should safety systems respond?	It makes the same action appear less acceptable after a severe result, although not every bad outcome is an error, so systems analyse process and context while recognising that consequences matter.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0006-en	Why does harm still occur in a system protected by multiple barriers?	Every barrier has weaknesses, and harm occurs when active failures align with latent conditions such as understaffing, poor layout, ambiguous labelling, incompatible software, or production pressure.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0007-en	What does the Swiss-cheese metaphor misrepresent, and why study successful adaptation as well as failure?	It can imply static holes, but real systems adapt as clinicians trade efficiency against thoroughness, and work-as-done differs from work-as-imagined; successful adaptation shows how safety is normally created.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0008-en	Why does redundancy not automatically increase safety, and how are standardisation and flexibility balanced?	Redundancy can introduce diffusion of responsibility or conflicting information; standardisation reduces unwanted variation, while flexibility is needed when cases fall outside the standard.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0009-en	Why is prospective memory a particular safety weakness, and what supports it?	Remembering to act later is especially fragile during interruptions; checklists and external reminders support cognition when they are integrated into the workflow.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0010-en	How can expertise increase the risk of anchoring, and what creates an opportunity to reframe?	Expertise improves pattern recognition, but familiar scripts can dominate contradictory evidence; diagnostic timeouts and second opinions create opportunities to reframe the problem.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0011-en	Why is naming cognitive biases insufficient, and what strategies work better?	Knowing the names does not reliably prevent bias; better strategies alter information flow by requiring alternatives, displaying trends, separating independent estimates, prompting disconfirming evidence, and creating outcome feedback.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0012-en	Why is fatigue addressed by system interventions rather than by urging individuals to be more resilient?	Circadian low points and extended wakefulness impair judgement even when clinicians feel adapted, so rostering, protected breaks, task design, and supervision are needed; exhortation cannot fully compensate.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0013-en	Why can performance look stable under rising workload and then fail suddenly?	Performance often remains stable until adaptive capacity is exhausted, after which a small additional demand produces disproportionate failure.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0014-en	Why are interruptions managed by design rather than simply eliminated?	Some interruptions communicate urgent information, so safety design separates necessary from avoidable interruption, protects high-risk tasks such as medication preparation, and provides a reliable way to resume.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0015-en	Why should training not be the sole remedy for defective design, and which design controls work better?	Look-alike names and packaging or hidden defaults invite predictable mistakes; forcing functions physically prevent unsafe action, constraints reduce options, and standardisation and affordances make intended use evident.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0016-en	Why can adding more alarms worsen detection?	High false-alarm rates cause desensitisation, competing noise, and delayed response; alarms should identify an actionable state with sufficient priority and specificity.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0017-en	What steps make communication closed-loop, and where is it especially valuable?	The sender names the recipient, states the message, receives a read-back, and confirms correctness, closing gaps from ambiguity and missing confirmation; it is especially valuable in resuscitation, medication orders, and critical results.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0018-en	What does psychological safety mean, and how can leaders counter hierarchy that suppresses challenge?	Team members can ask, admit uncertainty, and raise risk without humiliation, while standards remain; leaders invite dissent, state their own uncertainty, and respond appreciatively even when a concern proves unfounded.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0019-en	Which situations increase the risk of medication harm, and what reduces discrepancy?	High-alert drugs, renal or hepatic impairment, allergy labels, weight-based dosing, infusion concentration, transitions, and multiple prescribers raise risk; reconciliation and indication-linked prescribing reduce discrepancy.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0020-en	Why should the necessity of catheters and lines be reviewed daily?	Device use is one driver of healthcare-associated infection, and the safest catheter or line is often the one no longer present.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0021-en	Why do early-warning scores support rather than replace clinical judgement?	They aggregate observations but can miss clinical concern, atypical baselines, or abrupt change between measurements, so they work only within a full detection-and-response system.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0022-en	What is failure to rescue, and which system factors cause it?	It is failure to recognise or manage a complication in time, caused by normalising abnormal observations, diffusion of responsibility, delayed review, communication barriers, and mismatch between patient needs and ward capability.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0023-en	How does a just culture decide the response to an incident, and why does reporting depend on it?	It differentiates human error, at-risk behaviour, reckless conduct, and intentional harm, matching responses to context and choice; staff do not report when they expect punishment, futility, or excessive burden.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending
IMF-073-01-0024-en	Why cannot wellbeing programmes resolve the safety risk associated with burnout?	Burnout is not an individual defect but reflects workload, moral distress, inefficient systems, violence, discrimination, and inadequate control, so it cannot substitute for safe staffing and functional tools.	Integrated Medical Foundations; chapter 73, TTS module 1; https://theisegoria.github.io/medical-textbook/integrated-medical-foundations-expanded-english.md; module SHA256 at export: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856; editorial review pending	imf lang::en chapter::073 module::073-01 review::pending