NFO Conference: Att lära av varandra
Södertälje stadshus 3-4 Februari 2015
The good surgeon believes what he sees.
The bad one sees what he believes.
Seeing and believing
Good results come from experience.
Experience comes from bad results.
Richard I. Cook, MD Professor of Healthcare System Safety
School of Technology and Health
Royal Institute of Technology
Huddinge, SWEDEN
Copyright © 2015 by R.I.Cook for CTL
Copyright © 2015 by R.I.Cook for CTL
Key idea
• Why do we continue
to have accidents?
• Why don’t we have
more?
Available free at www.ctlab.org
Copyright © 2013 by R.I.Cook for CTL
Rasmussen’s system model
Rasmussen’s system model
Operating
point
Accident
Copyright © 2013 by R.I.Cook for CTL
Copyright ⓒ 2015 by Richard I. Cook, MD
Copyright © 2013 by R.I.Cook for CTL
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NFO Conference: Att lära av varandra
Södertälje stadshus 3-4 Februari 2015
Rasmussen’s system model
Rasmussen’s system model
MARGINAL
BOUNDARY
ACCIDENT
BOUNDARY
ACCIDENT
BOUNDARY
Counter-gradient
•New rules
•Recent accidents
•Safety campaigns
The operating point
tends to move towards
the accident boundary
Getting close to the
margin is a signal that
the operating point needs attention.
What is to be done?
Copyright © 2014 by R.I.Cook for CTL
Copyright © 2013 by R.I.Cook for CTL
Rasmussen’s system model
Rasmussen’s system model
Why doesn’t this lead to safe operations?
We usually don’t
know where the
accident boundary is.
ACCIDENT
BOUNDARY
MARGIN
Copyright © 2013 by R.I.Cook for CTL
Copyright © 2013 by R.I.Cook for CTL
Rasmussen’s system model
Rasmussen’s system model
Normalization of
deviance…
The result is often a
slipping of the operating
point towards the
accident boundary.
Dianne Vaughn
ACCIDENT BOUNDARY
…moves the marginal
boundary closer to the
accident boundary.
This is “flirting” with the margin
Copyright © 2013 by R.I.Cook for CTL
Copyright ⓒ 2015 by Richard I. Cook, MD
Copyright © 2013 by R.I.Cook for CTL
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NFO Conference: Att lära av varandra
Marginal
boundary
Accident
boundary
Blunt end
view (B)
Södertälje stadshus 3-4 Februari 2015
SAFETY
nd
rp e
Sha w (S)
vie
Marginal
boundary
Accident
boundary
OPPORTUNITY
Operating
point
ETY
SAF
ARD
HAZ
Experiments in search of
more efficient operations
Copyright © 2015 by R.I.Cook for CTL
Copyright © 2015 by R.I.Cook for CTL
Rasmussen’s system model
ecology
case: “soft” emergency
What is surprising is not that there
are so many accidents...
Cook & Nemeth, Taking things in one’s stride”,
Hollnagel et al., RE: Concepts and Precepts
③
OR SUITE
1
2
3
12
②
①
..it is that there are so few!
• how sick is this patient?
• what else do I have to do today?
• what leverage do I have?
• how do I maintain good
• why is it an emergency?
• consequence of bumping a
room for today’s work?
• what leverage do I have
• how do I maintain good
anesthesiologist
relationship with all the Ss?
But why?
Deeper knowledge
•how long to get the patient to the OR?
•how long before a room becomes empty?
•how fast is this surgeon?
•what else is pending?
•how truthful is S?
Deeper dependency
•nurse & anesthesia staffing
•different room geometries
•precedents and policies
•other obstacles
Copyright Copyright
© 2006 by
R.I.Cook
for CTL
© 2013
by R.I.Cook
for CTL
ecology
surgeon
1. demand
2. negotiation
3. agreement
relationship with A?
• what are the rules?
Deeper knowledge
• how will the patient’s condition change
with time?
• what happens if I don’t push hard
• what is happening in the other ORs?
• how long to get the patient to the OR?
Deeper dependency
•resident staffing
room geometries
•different
•precedents and policies
•other obstacles
deep socio-technical structure
Copyright © 2013 by R.I.Cook for CTL
ecology
case: “soft” emergency
Cook & Nemeth, Taking things in one’s stride”,
Hollnagel et al., RE: Concepts and Precepts
R is multiply contingent
variable time scales
• resilience is a property of the system
• resilience arises from system ecology
molecular
physics
anesthesiologist
surgeon
patient
hospital
characteristics
resources
human
professional roles
physiology
national funding
actions
anesthesiologist
relies upon
exploits
defends
disputes
surgeon
Resilience manifests at one scale
Resilience involves all the scales
deep socio-technical structure
Copyright © 2013 by R.I.Cook for CTL
Copyright ⓒ 2015 by Richard I. Cook, MD
time
(seconds)
Copyright © 2013 by R.I.Cook for CTL
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NFO Conference: Att lära av varandra
Södertälje stadshus 3-4 Februari 2015
Conclusions
ecology
Copyright © 2013 by R.I.Cook for CTL
Medical work system is
• complex
• dynamic
• adaptive
Every part of the
system is adapting
all the time.
Performance is much
better than it should be.
We have fewer
catastrophes
than expected.
The system operates
at the edge of failure.
It is too
expensive not
to do so.
We rely on resilience.
It is already
present in your
work system.
Challenge 2014-2020:
Invest in resilience
You are our
only hope.
Copyright © 2013 by R.I.Cook for CTL
Copyright © 2013 by R.I.Cook for CTL
Copyright ⓒ 2015 by Richard I. Cook, MD
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