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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)
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)
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)
Resilience, the ability to adapt or absorb disturbance, disruption, and change, may be increased by team processes in a complex, socio-technical system. In particular, collaborative cross-checking is a strategy where at least two individuals or groups with different perspectives examine the others’ assumptions and/or actions to assess validity or accuracy.(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)
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)