A 45-year-old male presented to a bustling urban Emergency Department in Calgary, Alberta, with vague abdominal discomfort, nausea, and a low-grade fever of 37.8°C. Dr. Lena Hanson, a PGY-3 emergency medicine resident, assessed him during a particularly high-volume night shift. She ordered a basic workup, including a CBC, which showed a WBC count of 12.5 x 10^9/L (slightly elevated). Due to the sheer number of critical patients requiring her attention and her own accumulating fatigue, Dr. Hanson focused on ruling out immediate life threats and, after a quick re-assessment, concluded the patient likely had viral gastroenteritis. She did not perform a detailed abdominal palpation. During the morning handover, she provided a brief update to the incoming resident, Dr. Marc Dubois, mentioning the patient as 'stable, likely viral, awaiting discharge' and did not specifically highlight the elevated WBC or the briefness of her abdominal exam. Dr. Dubois, also facing a full department, quickly reviewed the chart, noted the 'stable' status, and processed the discharge without a re-examination. Two days later, the patient returned to the ED with florid peritonitis, requiring emergent appendectomy for a ruptured appendix. The subsequent internal review highlighted several contributing factors. From a medical-legal and patient safety perspective, what overarching human factor concept best encapsulates the primary contributors to this adverse outcome?

A 78-year-old female, Ms. Eleanor Vance, is admitted to a tertiary care hospital in Calgary, Alberta, for community-acquired pneumonia. Her medical history includes well-controlled Type 2 Diabetes Mellitus managed with oral agents. During her admission, the attending internal medicine resident orders IV insulin for stress hyperglycemia. The hospital recently implemented a new, provincially mandated Computerized Physician Order Entry (CPOE) system. The resident, who received a brief online tutorial but no hands-on training, inadvertently orders 100 units of insulin instead of 10 units due to a default unit setting in the CPOE that wasn't clearly visible and a non-intuitive decimal placement option. The ward nurse, despite her due diligence in reviewing orders, also misses the significant dose discrepancy as the system's display visually obscured the decimal point for insulin units, especially during a busy night shift with high patient load. The patient subsequently develops profound hypoglycemia, leading to a seizure and requiring a prolonged stay in the intensive care unit with residual neurological deficits. An internal hospital review identifies that multiple similar 'near miss' incidents related to high-alert medication dosing have been reported with this specific CPOE interface, but no system-wide alerts or mandatory retraining sessions were implemented. Which of the following parties is most likely to bear the primary legal liability for this adverse patient outcome in a legal context?

Dr. Chen, a family physician in British Columbia, receives a formal notice from the College of Physicians and Surgeons of British Columbia regarding a complaint lodged by the daughter of a long-term patient, Mr. Dubois. The complaint alleges that Dr. Chen failed to adequately monitor Mr. Dubois's chronic kidney disease progression, leading to an avoidable hospitalization. Furthermore, the daughter claims that Dr. Chen's clinical notes appear to be incomplete and may have been retrospectively altered, and she also raises concerns about the physician's occasional 'erratic' behavior during consultations. Which of the following is the most appropriate initial step for Dr. Chen to take upon receiving this complaint?