A brief look at the New Look in complex system failure, error, and safety
Triggers

Accident Aftermath

Figuring
out what
happenedPatient
Preparing
centered
the accident
carestory

Formalinvestigations“Normal”
operations

Complex systems fail because of the
combination of multiple small failures, eachindividually insufficient to cause anaccident. These failures are latent in thesystem and their pattern changes over time.
Organizations, Institutions,Policies, Procedures,
Regulations

BLUNT
END

Hours

Days

Weeks

Months to years

Accident/incident investigation normallystops with error. Sterile incident collections
result. Learning halts. End of story.
Hindsight Bias

Before theAccident

Resources & Constraints

SHARP
END

Practitioner

Monitored Process

Practitioners at the sharp end of the systeminteract directly with the hazardous process.
The resources and constraints on theirtechnical work arise from institutional,management, regulatory, and technologicalblunt end factors.
Need to avoid
being sued
for malpractice
Need to protect
patient safety

Need to maintain
good relationships
to other professionals(e.g. surgeons)Pressure toreduce costs

Change surgery Maximize
to outpatient, preoperative
same dayworkup andadmission
information

Maximizepatient
turnoverAvoid technicalfailureBad
OutcomePrevent the heart muscle frombeing starved for oxygen
provide oxygento the heart muscle

keep heart muscle
work low
keep keep
heart blood
rate pressure
low
low

keep
keep
oxygenblood
pressure saturation
highhighkeep
oxygencarrying
capacityof bloodhighCompeting demands, dilemmas, conflicts,
and uncertainty are the central features ofoperations at the sharp end. Technical andorganizational conflicts overlap and interact.

Build good relations
with staff

Post-accident reviews identify human error
as the ‘cause’ of failure because ofhindsight bias. Outcome knowledge makes
the path to failure seem to have been
foreseeable - although it was not foreseen.
Quietperiod

Avoid injury to the heart

CONFLICT

Prepare forworkload surges

After theAccident

Save budget
Increase production
Invest in staff
experience for future
Save time forsicker patients
Avoid regulatory
scrutiny

Work at the sharp end inevitably encounterscompeting demands for production andfailure-free performance. Action resolves all
dilemmas. Successful operations are therule. Failure is rare.

Shift in lociof failures
More complex,
brittle system

Remedial
actionRetrospective
Review

Cycle of Error

Classification

Overt
Mechanical 15%
FailureHumanError

Complex
SystemFailure

85%

0%

Organizational reactions to failure focus onhuman error. The reactions to failure are:blame & train, sanctions, new regulations,rules, and technology. These interventions
increase complexity and introduce newforms of failure. Cycle repeats.
“New Look” learning
HumanError
Ineffective efforts(policies, procedures,new sanctions
clumsy technologies, etc.)“Investigation”

The usual approach

vulnerabilities, resilience,
hazards, expertise, conflicts,dilemmas, pressures

Makes possible
EffectiveChangetime“New Look” approach

People make safety. Improving safety
depends on understanding the details oftechnical work, how success is usuallyachieved, and how failure sometimes
occurs. Effective change follows.

Cognitive technologies Laboratory, Department of Anesthesia and Critical Care
University of Chicago, Chicago, IL 60637 e-mail: ri-cook@uchicago.edu
Copyright © 1991 - 1999 by R. I. Cook except as noted. All rights reserved
Revision E (99.06.02)