<p>Carrying out even the simplest of nursing activities can be a complicated process. Influences such as poor organisation, unforeseen events and inappropriate responses from those in authority can hinder nurses from meeting the most basic needs of a patient or performing a commonplace procedure. For example, consider the administration of an intravenous infusion (Box 1) (Deming 1987), which occurs frequently in hospital and increasingly in the patient’s home.</p>