My notes and other stuff


Accidents come from relationships, not parts

That's one solid quote right there, from Sidney Dekker's Drift Into Failure (p.67-68):

If systems really are complex [...], let’s start to live with that. We should start to act as if we really understood what that means. Complexity theory, rather than Newtonian reductionism, is where we should look for directions. That is what we should use to consider complex systems that risk drifting into failure. As said, with the introduction of each new part or layer of defense, technology, procedure, or specialization, there is an explosion of new relationships between parts and layers and components that spreads out through the system. Complexity theory explains how accidents emerge from these relationships, even from perfectly “normal” relationships, where nothing (not even a part) is seen as broken. The drive to make systems reliable, then, also makes them very complex – which, paradoxically, can in turn make them less safe. Redundancy or putting in extra barriers, or fixing them does not provide any protection against a system safety threat. In fact, it can help create it, or perpetuate or even heighten the threat. The introduction of a layer of technology (bar-code-scanning) for double-checking a medication order against a patient ID, for example, introduces new forms of work and complexity (the technology doesn’t work as advertised or hoped, it takes time and attention away from primary tasks, and it calls for new forms of creativity and resourcefulness).

Newton has been on a retainer for more than three centuries. There is something seductive about going down and in to find the broken part and fix it. We can try to tell professionals to be “more professional,” for example, or give them more layers of technology to forestall the sorts of component failures we already know about (only to introduce new error opportunities and pathways to failure). Complexity theory says that if we really want to understand failure in complex systems, that we “go up and out” to explore how things are related to each other and how they are connected to, configured in, and constrained by larger systems of pressures, constraints, and expectations.

We would ask why the nurse in question is at work already again this day after a break of only a few hours (that she spent trying to sleep in an empty hospital bed). We would find that she was filling in an empty slot created by the medical leave of a colleague, on a holiday weekend. Just below, we would find how the subtle but pressing requests to stay for another shift intersects with cultural and personal and deontological features of those we make into our nurses – of those whom we want to be our nurses, those who somehow incarnate commitment, dedication, those who are the embodiment of the “care” in healthcare.

We could trace such a situation to various managerial, administrative, political, and budgetary motivations of a hospital, which we could link to insurance mercantilism, the commercialization of disease, the demand for a commodification of health care’s prices and products. We would want to find how, since Florence Nightingale, nursing has steadily lost status, reward, and attraction, with ranks that are hard to fill, its traditional provision of succor eroded under the relentless industrialization of care, and its role as patient voice, as patient advocate now hollow, because there is always the next patient. And the next. And, if we have the societal courage, we might inquire after the conditions and collective norms that make it plausible for a 16-year-old girl among us in the community to be pregnant and in need of hospital care to begin with.

If we don’t dare to go there and undertake this line of inquiry, then it should be no surprise that the cumulative consequences suddenly emerge one day on the work floor of a busy, understaffed ward in a regional community hospital with a patient screaming in acute, severe pain, demanding that something be done now, now. If we tinker only gingerly with the final, marginal technical minutiae at various sharp ends, all of those systemic influences will collect again and again to shape what any other caregiver will see as the most rational course of action – no matter how large the label on the IV bag.