How practitioners adapt to clumsy technology
This is one of my favourite bits from Behind Human Error (note that there are many, many such bits in there and it is probably my bible for incident-related stuff):
Another consistent observation is that, rather than exploit device flexibility, we see practitioners externally constrain devices via ad hoc standards. Individuals and groups develop and stick with stereotypical routes or methods to avoid getting lost in large networks of displays, complex menu structures, or complex sets of alternative methods. For example, Figure 12.1 shows about 50 percent of the menu space for a computerized patient-monitoring information system used in operating rooms. We sampled physician interaction with the system for the first three months of its use during cardiac surgery. The highlighted sections of the menu space indicate the options that were actually used by physicians during this time period. This kind of data is typical - to cope with complexity, users throw away functionality to achieve simplicity of use tailored to their perceptions of their needs
Figure 12.1: This figure illustrates a portion of the menu space for a computerized patient-monitoring information system. The highlighted areas are the items actually used by practitioners during observations of device use in cardiac surgery over three months. Note that the space of possibilities is very large compared with the portion practitioners actually use.