Richard I. Cook

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Rather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled-that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer many(More)
Comparison of 46 handwritten and electromechanically generated blood pressure records revealed substantial differences between the recordings. The highest automated record pressures exceeded the highest pressures found in corresponding handwritten records. Similarly, the lowest pressures from automated records were lower than those from handwritten records.(More)
OBJECTIVE In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the(More)
Following celebrated failures stakeholders begin to ask questions about how to improve the systems and processes they operate, manage or depend on. In this process it is easy to become stuck on the label ‘human error’ as if it were an explanation for what happened and as if such a diagnosis specified steps to improve. To guide stakeholders when celebrated(More)
The flow of technical work in acute healthcare varies unpredictably, in patterns that occur regularly enough that they can be managed. Acute care organizations develop ways to hedge resources so that they are available if they are needed. This pragmatic approach to the distribution of work among and across groups shows how rules can be used to manage a(More)