Safety is more than the management of risk. It is more than the absence of accidents, avoidance of error or even the control of risk. Defining an organization as safe because it has a low rate of error or accidents has the same limitations as defining health in terms of not being sick (Rochlin, 1999; Hollnagel, 2012).

Performance measurement is a fundamental principle of managing organizations and digital management control systems (dMCS) and well defined key performance indicators (KPI’s) are seen to support the identification of performance gaps between current and desired performance and provide indication of progress towards closing the gaps. DMC's and KPI’s are also seen as potent control tools in error detection with the purpose to support safe practice and build resilient organizations (Hutchins, 1995).

Calls are being made to broaden the scope from seeing technology such as dMCS, in which KPI's are a part, as something taken for granted or being black-boxed and instead investigate how actors create meaning and make sense of such technology in their daily use of it (Orlikowski & Iacono, 2001; Ciborra, 2002; Orlikowski, 2007, Zetterquist et al., 2011). Like other technological artefacts the meaning of dMCS is largely a matter of its use (Zettequist et al., 2011).

The need for improved insight regarding the use of dMCS’ in organizations was early emphasized by Ashton (1976) who described how the use of dMCS' not only could risk resulting in unintended consequences, but also how the use of such systems and measurements could preserve unintended consequences by deviation-amplifying feedback.

Results from studies within a healthcare setting, a nuclear power plant and a school show how the use of dMCs, such as i.e. an incident reporting system, result in unintended consequences for students, patients and the community. The studies also show how the use of dMCS' and KPI’s furthermore can amplify negative effects over time.