tag:blogger.com,1999:blog-32053362.post4336694793592584358..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: How complex systems failPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-32053362.post-67566813955969109282012-07-20T08:10:06.600-04:002012-07-20T08:10:06.600-04:00There is a thread that runs through these observat...There is a thread that runs through these observations that might be considered a failure itself: the failure to see systems ecologically, and to analyze information in a more comprehensive, strategic and predictive manner. <br /><br />Our analogies continue to be of systems as machines, to be broken apart into components, and examined so. We assume independence of failures, except for very localized patterns in regard to place, provider, equipment, scheduling. 'Mixtures of failures', as if they are not related in predictable ways to each other. Different department, different problem. Which some are. Our analyses will not be adequate until our map matches the living organisms in play. <br /><br />I suggest an analogy that is closer to the evidence. Medical systems are ecologies of relationships between humans, tools, pathogens, and competing goals. To 'run in degraded mode' suggests conflicting optimizations given realized tradeoffs. These optimizations and tradeoffs, rather than just worn out caregivers and widgets, should also be the subject of measure and analysis. There is no ideal state – just as there is no ideal human body, or ideal physician, or ideal pharmaceutical. It is not a normative state that variation should be measured against, but an optimal state given conditions. This does not mean that harm should happen: it should not. But it will. And it will especially if we do not understand intersecting conditions in more sophisticated ways. It is a Buckminster Fuller argument: we are not matter, we are energy.<br /><br />For example,<br /><br />'Root causes' are not only inadequate for reasons described, but because they are never used to generate larger analytical recognition of patterns to clarify the relationships that led to their attention in the first place. And 'hindsight' and 'failure free' challenges for patient safety fall squarely in the 'do you know the animal you work with?' category. Humans never evolved to be perfect performers, even if medical school cultivated many to think it is possible. Meanwhile, our brains are well equipped to justify the difference, and move on. <br /><br />Improved 'Complex Systems Analyses' will require us to know more about ourselves, and variations in our interactions with others, tools, and environments, than simply deviation from idealized functions and parts. But it would allow us to look for opportunities to maximize cooperation in service of better work and safety environments, and to reorient interactions that corrode improvement.<br /><br />It also requires us to step up our intellectual and analytical game, as the true failure may be that we are not asking all the right questions yet.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-15221320746442663322012-07-17T22:19:35.235-04:002012-07-17T22:19:35.235-04:00I read this early today on my phone and only now h...I read this early today on my phone and only now have a chance to comment.<br /><br />First, as you probably know, I fully agree about complexity, so the fundamental point of this post is solid, IMO.<br /><br />But discouragement? HELL no; complexity is why it's usually erroneous to blame an *individual*, and complexity is why it's vital for everyone to share in the awareness that something could go wrong at any time, so "Let's all work together to be vigilant." <br /><br />And that in turn is why it's a problem for anyone (especially a surgeon) to get hostile about improvements or mistakes that are pointed out.<br /><br />Re: "Post-accident attribution accident to a ‘root cause’ is fundamentally wrong" - this point seems off base. As I understand it, the purpose of root cause analysis is to understand what happened; but do people who do it think there IS just one root cause? What do rigorous trainers say about that?<br /><br />All in all, this doesn't make me pessimistic because it doesn't mean there's no point in trying, and certainly doesn't mean there's no point in working together to do everything we can for safety and quality.e-Patient Davehttps://www.blogger.com/profile/16381434866099596466noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-26546455036106797142012-07-17T20:20:38.318-04:002012-07-17T20:20:38.318-04:00Nevil Shute, in his autobiography "Slide Rule...Nevil Shute, in his autobiography "Slide Rule", gives an interesting history of the development of the rigid airship R-100 from 1926 to 1930 and the subsequent crash on its first flight (from England to India) in 1931. This histstory, along with his history of the development of R-101 in the same period, clearly illustrate the points of this article.Ian E. Gormannoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-77502169091287662832012-07-17T10:52:36.921-04:002012-07-17T10:52:36.921-04:00This is similar to Leveson's work with STAMP a...This is similar to Leveson's work with STAMP and CAST. (See http://sunnyday.mit.edu/)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-80491317189127298672012-07-17T02:05:30.932-04:002012-07-17T02:05:30.932-04:00thank for the great and insightful post.
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