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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)
The effects of new technology on human performance in domains such as anesthesiology, commercial aviation, and nuclear power operations remain controversial. To study the impact of new technology on skilled practitioner performance, we observed the introduction of a new, highly integrated, microprocessor-based physiological monitoring system for use in(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)
Healthcare systems, especially hospital operating room suites, have properties that make them ideal for the study of the cognitive work using the naturalistic decision-making (NDM) approach. This variable, complex, high-tempo setting provides a unique opportunity to examine the ways that clinicians plan, monitor, and cope with the irreducible uncertainty(More)
Studies of patient safety have identified gaps in current work including the need for research about communication and information sharing among health care providers. They have also encouraged the use of decision support tools to improve human performance. Distributed cog-nition is the shared awareness of goals, plans, and details that no single individual(More)
The patient safety movement, from the beginning, has been stimulated by ideas from the fields of human factors and high reliability organizations [1,2] and health care leaders consistently refer to the potential value of these human factors results as a guide for methods, investment, and change [3,4]. Jump starting improvements in patient safety by simply(More)