# 01 Roles and Responsibilities

> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-GOV-01.
>
> Canonical: https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities
>
> Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/)
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> General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca.

## 1. Purpose

To set out who is responsible for what in the safety management system, so that every duty in law and every element of every program has a named role, and so that every person in the department can see their own part. Every program module and policy in this package refers back to this note and records only the differences.

## 2. The principles behind the assignments

**The internal responsibility system.** Canadian occupational health and safety law rests on the idea that everyone in the workplace shares responsibility for health and safety, in proportion to their authority and ability to act, and that the people closest to the work are best placed to identify hazards [(Ham, 1976)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-ham-1976). The employer carries the greatest responsibility because it has the most control. Supervisors are responsible for the work they direct. Workers are responsible for working safely and reporting hazards. The JOHSC and the regulator are checks on the system, not substitutes for it. Several jurisdictions write the internal responsibility system into the purpose of their statute, and statutes differ on whether supervisors are separate duty-holders or are reached through the employer’s duties ([J02 Duties of Employers, Supervisors, Workers and Contractors](https://thehumanfactor.ca/library/fire-service-safety/j02-duties-of-employers-supervisors-workers-and-contractors)).

**Due diligence.** Under provincial OHS law, an employer, supervisor or officer charged with an offence may defend by showing it took every precaution reasonable in the circumstances (*R. v. Sault Ste. Marie*, 1978). Under section 217.1 of the Criminal Code (the Westray amendments), everyone who undertakes, or has the authority, to direct how another person does work or performs a task is under a legal duty to take reasonable steps to prevent bodily harm to that person, or any other person, arising from that work [(Criminal Code \[CA\], 1985, s. 217.1)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-criminal-code-ca). Due diligence is shown by records: hazard assessments, procedures, training, supervision, inspection, enforcement, corrective action. This package is designed so that those records exist as a by-product of running the programs.

**Line ownership.** The chain of command owns safety. Every operational risk is owned by the line officer who directs the work, and every program is owned by a line program manager through its Program Improvement Team ([06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams)). The health and safety officer advises, coordinates, verifies and audits [(NFPA 1550, 2024, ch. 4 and 6.8)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-nfpa-1550). The JOHSC participates, inspects, recommends and holds the employer to account. None of these replace the line. ISO 45001 places the same expectation on top management: leadership and commitment cannot be delegated, and roles, responsibilities and authorities must be assigned and communicated (ISO 45001:2018, cl. 5.1 and 5.3; CSA Z45001:19).

**One accountable owner.** Each element has exactly one accountable role. Responsibilities may be shared; accountability is not.

**People are the solution we build around.** Roles in this package are written to help people do the work well, not to locate blame after it goes wrong. Procedures describe work as done, written with the people who do it [(Hollnagel, 2014)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-hollnagel-2014). Learning comes before blame, and learning information is never used for discipline; conduct concerns go to a separate process run by different people ([Dekker, 2016](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-dekker-2016); [Reason, 1997](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-reason-1997)). Psychological safety, the shared belief that it is safe to speak up, ask, admit an error or challenge a decision, is a condition of safety, so speaking up is expected of every role and protected by every supervisor [(Edmondson, 1999)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-edmondson-1999). Every role below therefore carries two duties that never appear on an organization chart: to raise a concern when something looks wrong, and, for anyone who supervises, to answer the person who raised it.

## 3. Role definitions and duties

Role titles are generic. Map them to the department’s ranks in the table at section 6.

### 3.1 Municipal council (or governing board)

- Establishes the fire service and sets its level of service.
- As the employer of record in most municipalities, carries the employer’s statutory OHS duties, exercised through the chief administrative officer and the fire chief.
- Approves the budget that resources the safety management system.
- Receives the annual health and safety report for the fire service ([03 Accountability and Reporting](https://thehumanfactor.ca/library/fire-service-safety/accountability-and-reporting)).

### 3.2 Chief administrative officer (or city manager)

- Ensures the municipality’s corporate OHS policy and program apply to the fire service, and that the fire service’s program meets or exceeds them.
- Ensures corporate services (human resources, fleet, facilities, procurement, legal, risk management) support the fire service’s program with service levels that are written down.
- Receives the fire chief’s annual report and escalations.

### 3.3 Fire chief

Accountable for the safety management system as a whole.

- Signs and publicly commits to the OHS policy; posts it in every station.
- Ensures the department has the written OHS program, the JOHSC (or safety representative), and every statutory policy and plan that applies.
- Appoints the senior officer responsible for health and safety and the health and safety officer, gives them the authority and time to do the work, and ensures they report directly enough to be heard.
- Ensures every program has a Program Improvement Team or a named owner.
- Responds in writing to every JOHSC recommendation within 21 days, or sooner where the statute requires.
- Chairs the annual management review; approves the annual health and safety objectives and the corrective action priorities.
- Ensures safety is resourced in the budget, and that safety-critical gaps are escalated to the CAO and council in writing when they cannot be resourced.
- Models the behaviour: wears PPE, follows procedures, reports.

### 3.4 Deputy chiefs (operations, administration, or equivalent)

- Accountable for the programs in their area, through the program managers who report to them.
- Ensure supervisors under their command are trained and held accountable for safety duties.
- Review quarterly program updates; escalate overdue corrective actions at 30 days.
- Chair or attend the operations meeting where safety indicators are reviewed monthly.

### 3.5 Senior officer responsible for health and safety ({{Division Chief, Safety}})

- Leads the safety division; maintains the safety management system documents, hazard profile and risk register, audit program and Corrective Action Register.
- Advises the fire chief and senior team; reports safety performance monthly and annually.
- Ensures the health and safety officer function and the incident safety officer function are staffed and competent.
- Is the employer co-chair of the JOHSC, or designates the employer co-chair, as the department decides.
- Coordinates with the municipality’s corporate safety function and the regulator.
- Leads incident investigation and learning for serious events in partnership with the JOHSC.

### 3.6 Health and safety officer ({{Health and Safety Officer}})

The program-level safety officer (NFPA 1550 health and safety officer function). May be the same person as 3.5 in a smaller department.

- Coordinates the safety management system day to day; supports Program Improvement Teams as standing consultant.
- Verifies that programs meet law and standards; samples records; runs the internal audit schedule.
- Maintains the injury, exposure and near-miss data and the indicator dashboard.
- Ensures workplace inspections happen on schedule and findings are logged.
- Reviews new and changed procedures, equipment and PPE for safety before JOHSC consultation.
- Ensures statutory reports are made to the regulator and workers’ compensation board on time.
- Has the authority to stop any activity, including training, that presents an imminent hazard, and to report directly to the fire chief.

### 3.7 Incident safety officer ({{Incident Safety Officer}})

The incident-level safety officer function within the incident management system.

- Is assigned at incidents and training evolutions according to the Emergency Operations Safety program triggers.
- Monitors conditions, activities and operations; assesses risk; advises the incident commander.
- Has the authority to alter, suspend or terminate any activity that presents an imminent hazard, and informs the incident commander immediately.
- Participates in the post-incident review and feeds observations into the learning system.

### 3.8 Training officers and instructors

- Deliver training to the program’s standard; enforce training safety rules; assign a training safety officer for high-hazard training and live fire.
- Keep training and competency records.
- Serve as the training officer assigned to Program Improvement Teams.

### 3.9 Program managers (line officers leading Program Improvement Teams)

Accountable for their programs. Full duties in [06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams) section 3.1.

### 3.10 District, battalion or platoon chiefs (supervisors of supervisors)

- Ensure company officers in their district or platoon carry out their supervisory safety duties.
- Review injury, exposure and near-miss reports from their area within 24 hours; ensure first-level investigation is done.
- Conduct or verify station inspections on schedule.
- Act as incident commander and assign incident safety officers per the triggers.
- Reinforce procedures; correct unsafe practice; recognize good practice.

### 3.11 Company officers (captains, lieutenants, station officers, volunteer officers)

The supervisor in law for the crew. The most important safety role in the department.

- Know the hazards of the work they direct, and tell the crew about them.
- Ensure crew members are trained, competent and fit for the task before assigning it.
- Ensure crew members wear and use required PPE and follow procedures; correct deviations immediately.
- Conduct the start-of-shift or start-of-call checks: crew readiness, apparatus and SCBA checks, PPE condition.
- Account for the crew at all times on the fireground; maintain crew integrity.
- Ensure every injury, exposure and near miss is reported before the end of the shift, and complete the supervisor’s section of the report.
- Ensure post-call decontamination and PPE cleaning procedures are followed.
- Hold the hot debrief after significant calls; refer events for review per the learning program triage ([Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program)).
- Respond to a member’s safety concern, and to a work refusal, as the procedure requires. Answer every concern raised, in person where possible, by the end of the shift: what will happen, who owns it, when the member will hear back. Thank the member for raising it, whatever the outcome.
- Run the crew so that speaking up is normal: ask for concerns at the start of the shift and at the end of every significant call; acknowledge a stop-work call immediately and review it later for learning, never for blame.
- Participate in station inspections and correct findings within their authority.

### 3.12 Firefighters and members (career, volunteer and paid-on-call)

- Work in accordance with training, procedures and the law; use the PPE and equipment provided, as trained.
- Report hazards, injuries, exposures, near misses and equipment defects to the supervisor right away.
- Take part in training, medical evaluations, fitness assessments and fit testing as required.
- Keep issued PPE clean, inspected and in service condition; report damage.
- Look out for crew members; speak up when something is unsafe (the stop-work authority applies to everyone).
- Know the right to refuse unsafe work and how to exercise it.
- Not work while impaired by alcohol, drugs, fatigue or a medical condition that makes them unfit; tell the supervisor.
- Take part in Program Improvement Teams, learning teams and the JOHSC when asked or elected.

### 3.13 Joint occupational health and safety committee ({{JOHSC}})

Full role in [02 JOHSC Integration](https://thehumanfactor.ca/library/fire-service-safety/johsc-integration). In summary: identifies hazards; receives and considers concerns and complaints; participates in the development of the OHS program and its policies and procedures; makes written recommendations to the employer and tracks the response; carries out regular workplace inspections; participates in investigations; reviews injury and exposure data; is consulted on safety-sensitive changes; designates standing consultants to Program Improvement Teams.

### 3.14 Union and volunteer association

- Nominate or elect worker members of the JOHSC as the law and the collective agreement provide.
- Nominate representatives to the Equipment Standards team and other teams as agreed.
- Participate in work refusal investigations where the procedure calls for it.
- Partner in health, wellness and peer support programs.

### 3.15 Department physician or occupational health provider

- Provides medical evaluations to the standard adopted (NFPA 1580 or the department’s chosen protocol); determines medical fitness for duty and for respirator use; keeps medical records confidential and separate.
- Advises on rehab protocols, infection control, exposure follow-up and return to work.
- Sits as clinical adviser to the Health, Wellness and Rehab team and the Respiratory Protection team.

### 3.16 Peer support team

- Provides confidential peer support after critical incidents and for members in difficulty, within its training and the program’s protocol; refers to clinical care.
- Reports aggregate activity only.

### 3.17 Corporate services (human resources, fleet, facilities, procurement, legal, risk management)

- Human resources: workers’ compensation claims, return to work and accommodation, medical records custody, investigations under the harassment and violence programs.
- Fleet: apparatus maintenance and testing to the program’s standard and schedule, under a written service level agreement.
- Facilities: station maintenance, building systems, diesel exhaust systems, asbestos and indoor air quality management.
- Procurement: buys to the specifications the Equipment Standards team sets; never substitutes safety equipment on price without the team’s sign-off.
- Legal and risk management: advice on investigations, records, privacy, regulator contacts.

### 3.18 Contractors, suppliers and mutual aid partners

- Contractors working in fire service workplaces follow the Contractor and Mutual Aid Safety program and the department’s site rules.
- Suppliers provide equipment that meets the specified standards with the documentation required.
- Mutual aid partners operate within the incident management system and accountability system of the host incident; written agreements address safety expectations.

## 4. RACI matrix

R = responsible (does it), A = accountable (one per row), C = consulted, I = informed.

| Element | Council/CAO | Fire chief | Deputy chief | Sr officer H&S | HSO | Program manager | Company officer | Member | JOHSC | Union/Assoc. |
|:---|:---|:---|:---|:---|:---|:---|:---|:---|:---|:---|
| OHS policy (signed, posted) | I | A | C | R | C |  | I | I | C | C |
| Written OHS program | I | A | C | R | R | C | I | I | C | C |
| Hazard profile and risk register |  | I | C | A | R | R | C | C | C |  |
| Program content (each program) |  | I | A | C | C | R | C | C | C | C |
| Safe work procedures |  | I | C | C | C | A | R | C | C | C |
| Training and competency |  | I | A | C | C | R | R | R | I | I |
| PPE and equipment standards |  | I | A | C | C | R | I | C | C | C |
| Workplace inspections |  | I | C | A | R |  | R | C | R |  |
| Injury, exposure and near-miss reporting |  | I | I | A | R |  | R | R | I | I |
| Investigation of serious events |  | I | C | A | R | C | C | C | R | C |
| JOHSC recommendations and response |  | A | C | R | C | C |  |  | R | I |
| Work refusals |  | I | C | C | R |  | A | R | R | C |
| Statutory reporting to regulator and WCB |  | I |  | A | R |  | C |  | I |  |
| Medical evaluations and fitness |  | I | C | A | C | R |  | R | I | C |
| Corrective Action Register |  | I | C | A | R | R | R |  | I |  |
| Internal audit |  | I | I | A | R | C | C | C | C |  |
| Management review | I | A | R | R | R | C |  |  | C |  |
| Annual H&S report to council | I | A | C | R | R | C |  |  | C | I |
| Budget for safety | A | R | R | C | C | R |  |  | I |  |

## 5. Authority to stop work

Every member has the authority and the duty to stop an activity they believe presents an imminent danger to themselves or another person, and to tell the supervisor right away. The incident safety officer, the health and safety officer and the training safety officer have express authority to alter, suspend or terminate an activity [(NFPA 1550, 2024, ch. 4 and 5)](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-nfpa-1550). Stop-work calls made in good faith are never the subject of reprisal, and are reviewed for learning whatever the outcome. This is separate from, and in addition to, the statutory right to refuse unsafe work ([Policy - Right to Refuse Unsafe Work and Stop-Work Authority](https://thehumanfactor.ca/library/fire-service-safety/policy-right-to-refuse-unsafe-work-and-stop-work-authority)).

**How to stop work, in one breath.** Name the hazard, name the action: “Stop. The floor is spongy by the stairs. Back out to the door.” The officer acknowledges (“Copy, backing out”), acts, and reviews the call afterward with the crew as a learning question: what did you see that we did not?

## 6. Mapping table (complete for the department)

| Generic role in this package | {{Department}} title(s) | Number of positions | Named in the department’s organization chart? |
|:---|:---|:---|:---|
| Fire chief |  |  |  |
| Deputy chief, operations |  |  |  |
| Deputy chief, administration or support |  |  |  |
| Senior officer responsible for health and safety |  |  |  |
| Health and safety officer |  |  |  |
| Incident safety officer (qualified pool) |  |  |  |
| Training safety officer (qualified pool) |  |  |  |
| Program managers |  |  |  |
| District / battalion / platoon chiefs |  |  |  |
| Company officers (career) |  |  |  |
| Company officers (volunteer) |  |  |  |
| Firefighters (career) |  |  |  |
| Firefighters (volunteer / paid-on-call) |  |  |  |
| JOHSC co-chairs |  |  |  |
| Department physician / occupational health provider |  |  |  |
| Peer support team lead |  |  |  |

> **Note: Customize**
>
> Fill in section 6, then check every “A” in the RACI against a real position with the authority to deliver it. If an “A” lands on a role that has no budget, no time or no authority over the people doing the work, fix the organization or move the “A”; do not leave it on paper. In a small department the senior officer, HSO and program manager roles may be held by two or three people; record who holds what.

> **Tip: Volunteer and composite departments**
>
> Volunteer company officers are supervisors under the department’s policies when they direct work; whether volunteers are workers and supervisors in law depends on your jurisdiction ([J11 Volunteer Firefighters](https://thehumanfactor.ca/library/fire-service-safety/j11-volunteer-firefighters)). They need the same supervisory safety training as career officers, delivered at times they can attend. Record their supervisory training separately so the audit can see it.

## 7. Supervisor safety competency (minimum)

Every person in a supervisory role (company officer and above, career and volunteer) completes, within six months of appointment and before acting as incident commander:

1.  OHS law for supervisors in the department’s province or territory (duties, due diligence, Criminal Code s. 217.1, right to refuse, reporting; see [J02 Duties of Employers, Supervisors, Workers and Contractors](https://thehumanfactor.ca/library/fire-service-safety/j02-duties-of-employers-supervisors-workers-and-contractors)).
2.  The department’s safety management system: programs, reporting, investigation, corrective action.
3.  Hazard identification and risk assessment for the fireground and the station.
4.  Incident safety: IMS, accountability, RIT, mayday, air management, rehab, when to assign an ISO.
5.  Exposure and contamination control, and what the officer must do after every fire.
6.  Human factors for officers: fatigue, decision-making under stress, crew resource management, speaking up, just culture.
7.  Responding to injuries, exposures, near misses and work refusals.
8.  Psychological health: recognizing distress, peer support referral, post-incident check-ins.
9.  Psychological safety for officers: how to ask for concerns, how to answer them, how to receive a stop-work call or a challenge to a decision, and why the officer’s response to the first report decides whether there will be a second ([Edmondson, 1999](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-edmondson-1999); [Westrum, 2004](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities#ref-westrum-2004)).

Record: name, role, date of each module, assessor. Refresh every three years and after any change in law or program.

## 8. Accountability and closed feedback loop for this note

| Element | Who | How |
|:---|:---|:---|
| Owner | Fire chief | Approves the role assignments and the RACI |
| Doer | Senior officer responsible for H&S | Maintains this note, the mapping table and supervisor competency records |
| Verifier | Internal audit (annual), JOHSC (consulted at each revision) | Audit samples five “A” assignments and checks the role-holder can describe and evidence them |
| Feedback | Management review | Gaps in authority or resourcing reported annually |
| Member’s concern route | Any member to their supervisor, or to any JOHSC member | Supervisor answers by end of shift; unresolved items go to the Corrective Action Register within five working days, and the member is told the register number and owner |
| Closure | Corrective Action Register | Any “A” without capacity is logged with an owner and due date |

**Loop test.** An audit finds that program managers are accountable for program budgets but cannot submit budget lines. The finding is logged that week. The fire chief resolves it at the next management review, the RACI and the budget process are amended, and the change is communicated to every program manager.

**Psychological-safety indicator for this note.** Percentage of members who agree, in the annual culture survey, that “if I raise a safety concern with my officer, I get an answer” ([05 Safety Culture Baseline](https://thehumanfactor.ca/library/fire-service-safety/safety-culture-baseline)). Target: rising year on year; any station below the department mean gets a learning-team session, not a reprimand.

## Definitions

- **Accountable.** The single role that answers for an outcome and has the authority to deliver it.
- **Due diligence.** Taking every precaution reasonable in the circumstances to prevent harm; the defence to a strict liability OHS offence.
- **Internal responsibility system.** The principle that everyone in the workplace shares responsibility for health and safety in proportion to their authority and ability to act.
- **Line ownership.** Accountability for a risk or program held by the officer who directs the work, not by a staff safety function.
- **Psychological safety.** The shared belief in a team that it is safe to speak up, ask a question, admit an error or challenge a decision without punishment or humiliation.
- **RACI.** A matrix showing who is responsible, accountable, consulted and informed for each element.
- **Stop-work authority.** The authority and duty of any member to halt an activity that presents an imminent danger, separate from the statutory right to refuse.
- **Supervisor.** A person who directs the work of others. Statutes differ on whether a supervisor is a separate duty-holder or is reached through the employer’s duties ([J02 Duties of Employers, Supervisors, Workers and Contractors](https://thehumanfactor.ca/library/fire-service-safety/j02-duties-of-employers-supervisors-workers-and-contractors)).

## Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

| Topic | What to check in your jurisdiction | Page |
|:---|:---|:---|
| Duties of Employers, Supervisors, Workers and Contractors | The wording of the employer’s general duty (including information, instruction, training and supervision), whether the statute names the internal responsibility system, and whether company officers are separate duty-holders as supervisors or are reached through the employer’s duties | [J02 Duties of Employers, Supervisors, Workers and Contractors](https://thehumanfactor.ca/library/fire-service-safety/j02-duties-of-employers-supervisors-workers-and-contractors) |
| Joint Committee and Health and Safety Representative | The deadline for the employer’s written response to a committee recommendation, which governs wherever it is shorter than the 21 days this chapter sets | [J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative) |
| Right to Refuse and Reprisal Protection | The steps of a statutory work refusal and the protection from reprisal, on which the stop-work authority in section 5 builds | [J07 Right to Refuse and Reprisal Protection](https://thehumanfactor.ca/library/fire-service-safety/j07-right-to-refuse-and-reprisal-protection) |
| Volunteer Firefighters | Whether volunteers are workers under the OHS statute, and whether a volunteer officer who directs work carries a supervisor’s duties | [J11 Volunteer Firefighters](https://thehumanfactor.ca/library/fire-service-safety/j11-volunteer-firefighters) |

## References

Criminal Code, R.S.C. 1985, c. C-46 (Canada; consolidated to 2026-09-30; ss. 22.1, 22.2 and 217.1). <https://laws-lois.justice.gc.ca/eng/acts/c-46/>

CSA Group. (2019). *CSA Z45001:19 (R2023), Occupational health and safety management systems: Requirements with guidance for use* (adopts ISO 45001:2018 with Canadian deviations). <https://www.csagroup.org/store/product/CSA%20Z45001:19/>

Dekker, S. (2016). *Just culture: Restoring trust and accountability in your organization* (3rd ed.). CRC Press.

Edmondson, A. C. (1999). Psychological safety and learning behavior in work teams. *Administrative Science Quarterly, 44*(2), 350–383. https://doi.org/10.2307/2666999

Ham, J. M. (1976). *Report of the Royal Commission on the Health and Safety of Workers in Mines*. Government of Ontario.

Hollnagel, E. (2014). *Safety-I and Safety-II: The past and future of safety management*. Ashgate.

International Organization for Standardization. (2018). *ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use*. <https://www.iso.org/standard/63787.html>

National Fire Protection Association. (2024). *NFPA 1550, Standard for emergency responder health and safety* (consolidates NFPA 1500, 1521 and 1561). <https://www.fire-police-ems.com/NFPA1550-2024.shtml>

*R. v. Sault Ste. Marie (City)*, \[1978\] 2 S.C.R. 1299 (Supreme Court of Canada).

Reason, J. (1997). *Managing the risks of organizational accidents*. Ashgate.

Westrum, R. (2004). A typology of organisational cultures. *Quality and Safety in Health Care, 13*(Suppl. 2), ii22–ii27. https://doi.org/10.1136/qshc.2003.009522