Richard Cook

Adaptive Capacity Labs

Knowledge and understanding of below-the-line structure and function are continuously in flux. Near-constant effort is required to calibrate and refresh the understanding of the workings, dependencies, limitations, and capabilities of what is present there. In this dynamic situation no individual or group can ever know the system state. Instead, in...

a set of 5 short articles on human performance and business critical software infrastructure including: 1. It’s time to revise our appreciation of the human side of Internet-facing software systems. 2. Above the Line, Below the Line. 3. Cognitive Work of Hypothesis Exploration during Anomaly Response. 4. Managing the Hidden Costs of Coordination. 5...

Objective The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE). Methods Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical recor...

Objective: To explore cognitive strategies clinicians apply while performing a medication reconciliation task, handling incomplete and conflicting information. Background: Medication reconciliation is a method clinicians apply to find and resolve inconsistencies in patients' medications and medical conditions lists. The cognitive strategies clin...

The modern “system” is a constantly changing melange of hardware and software embedded in a variable world. Together, the hyperdistribution, fluctuant composition, constantly varying workload, and continuous modification of modern technology assemblies comprises a unique challenge to those who design, maintain, diagnose, and repair them. We are inv...

A description of what makes studying cognitive work in the SRE community critically important.

Cognitive engineering is an interdisciplinary approach to the analysis, modeling, and design of engineered systems or workplaces in which humans and technologies jointly operate to achieve system goals. As individuals, teams, and organizations become increasingly reliant on information technology and automation, it is more important than ever for s...

Patient safety is firmly established as a major concern in the technologically advanced countries. It is clear that the processes of medical care itself harm patients directly and indirectly. The past 20 yrs have produced numerous cases, studies, reports, papers, meetings, and conventions dedicated to the subject and governments have expended billi...

Rationale Proponents and critics agree that health IT plays an important role in patient care and patient safety. Rather than being an adjunct or appendage of health care delivery, health IT is necessarily intimately woven into the fabric of patient care. Electronic medical records, digital imaging, provider order entry, and test results delivery d...

Like other high hazard sectors, successful crisis response relies on a well-founded understanding of the work domain and the manner in which operators perceive and deal with obstacles to achieving goals. That understanding is essential to the development of information and communications technology (ICT) that are intended to support operator perfor...

The present discussion panel addresses the need and possible approaches for providing integrative and inclusive human factors design of medical work units. An associated question is whether such a design perspective can be achieved without the instantiation of in house human factors teams. While recognition of the general importance and possible co...

Patients are most at risk during transitions in care across settings and providers. The communication and reconciliation of an accurate medication list throughout the care continuum are essential in the reduction in transition-related adverse drug events. Most current research focuses on the outcomes of reconciliation interventions, yet not on the...

Medication omissions and dosing failures are frequent during transitions in patient care. Medication reconciliation (MR) requires bridging discrepancies in a patient’s medical history as a setting for care changes. MR has been identified as vulnerable to failure, and a clinician’s cognition during MR remains poorly described in the literature. We s...

Resilience engineering strives to build the adaptive capacity of systems that is essential to continue operations in the face of substantial challenges. The healthcare enterprise provides a compelling opportunity to consider resilience as a desirable trait of systems. Clinicians, from physicians to nurses and technicians, are a source of resilience...

Erik Hollnagel's body of work in the past three decades has molded much of the current research approach to system safety, particularly notions of ''error''. Hollnagel regards ''error'' as a dead-end and avoids using the term. This position is consistent with Rasmussen's claim that there is no scientifically stable category of human perfor- mance t...

Yes Yes

We report on a human factors evaluation project at a major urban teaching hospital that was intended to use human factors methods to assist the selection of a new infusion device among 4 commercially available models. The project provided an expert evaluation of the pumps, collected data on programming each pump by a sample of practitioners, tabula...

Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress. As an emergent property of systems that is not tied to tallies of adverse events or estimates of their probab...

A widely reported ABO-mismatch accident in March of 2003 raised concerns about the reliability of the transplantation system. Because this type of failure is rare and significant, we performed a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation. A probabilistic risk assessment was perfo...

Healthcare information technology (IT) systems can be used to inform workers and managers about changes to workplace vulnerabilities and new means that may be available to meet challenges such as widely varying demand. IT system success, though, depends on adaptability in the face of change, which is a property that IT systems do not currently demo...

System performance in healthcare pivots on the ability to match demand for care with the resources that are needed to provide it. High reliability is desirable in organizations that perform inherently hazardous, highly technical tasks. However, healthcare's high variability, diversity, partition between workers and managers, and production pressure...

Making sense of circumstances and situations is critical to coordinate cooperative work. Especially in process control domains, we may expect that effective and reliable organizations will possess processes that develop, maintain, distribute, and, when necessary, repair this social understanding (sensemaking). Our research has focused on collective...

The flow of technical work in acute healthcare varies unpredictably, in patterns that occur regularly enough that they can be managed. Acute care organizations develop ways to hedge resources so that they are available if they are needed. This pragmatic approach to the distribution of work among and across groups shows how rules can be used to mana...

Resilience, the ability to adapt or absorb disturbance, disruption, and change, may be increased by team processes in a complex, socio-technical system. In particular, collaborative cross-checking is a strategy where at least two individuals or groups with different perspectives examine the others' assumptions and/or actions to assess validity or a...

Although proponents of advanced information technology argue that automation can improve the reliability of health care delivery, the results of introducing new technology into complex systems are mixed. The complexity of the health care workplace creates vulnerabilities and problems for system designers. In particular, some forms of failure emerge...

Transitions between shifts in the intensive care unit (ICU) create potential gaps in the continuity of care, and practitioners necessarily rely on distributed cognition to prevent the formation of gaps during work-cycle shift changes. The complexity and uncertainty of each ICU patient's condition require efficient communication between practitioner...

Thorough, objective investigation of medical adverse events rarely happens due to the com- plexity of the environment, litigation, risk, and socio-political implications. Special concerns can, and do, undermine investigation depth, breadth, and quality. Healthcare's distinct differ- ence from other high hazard sectors requires a unique approach to...

A case of synthesis of cognitive system functions-Richard Cook's (1998) Being "Bumpable" study of Intensive Care Units-illustrates the techniques and difficulties as one sets out to discover how real JCSs function. This is a case that unlocked aspects of the nature of practice. The starting point is to model the significance of insiders' use of a h...

Healthcare systems, especially hospital operating room suites, have properties that make them ideal for the study of the cognitive work using the naturalistic decision-making (NDM) approach. This variable, complex, high-tempo setting provides a unique opportunity to examine the ways that clinicians plan, monitor, and cope with the irreducible uncer...

Over the past several years, there has been an increase in interest in translating human factors knowledge and methods, primarily used in complex, event-driven, sociotechnical settings such as aviation, to health care. In this article, we overview the primary concepts in cognitive systems engineering that may aid in formulating interventions in a v...

Information technology (IT) systems have been described as brittle and prone to automation surprises. Recent reports of information system failure, particularly computerized physician order entry (CPOE) systems, shows the result of such IT failure in actual practice. Such mismatches with healthcare work requirements require improvement to IT resear...

There has been a longstanding consensus that supporting error detection and recovery processes is critical for very high safety levels because it increases system resilience. System resilience is defined in Resilience Engineering as successful adaptation to variations, changes, and surprises by organizations, groups, or individuals. Cross-checking...

With the rise in chronic, behavior-related disease, computerized behavioral protocols (CBPs) that help individuals improve behaviors have the potential to play an increasing role in the future health of society. To be effective and widely used CBPs should ...

Rather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled-that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer man...

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Although proponents of advanced information technology argue that automation can improve the reliability of health care delivery, the results of introducing new technology into complex systems are mixed. The new forms of failure that accompany automation challenge technical workers, often demanding novel approaches to recovering from failure and re...

Healthcare demonstrates the same properties of risk, complexity, uncertainty, dynamic change, and time-pressure as other high hazard sectors including aviation, nuclear power generation, the military, and transportation. Unlike those sectors, healthcare has particular traits that make it unique such as wide variability, ad hoc configuration, evanes...

The failure of automation to improve clinical performance is likely rooted in the design concepts on which IT systems are based. Current systems provide clinicians with specific direction about how to care for individual patients. This is much like the specific, detailed, complicated, and narrow trip route driving directions that can be obtained fr...

Objective: To fulfill the promise of information technology in health care, automation must be made into a “team player.” Methods: Observational research in both the laboratory and field focused on how subjects program infusion devices. These programming activities were examined in detail for a set of tasks, using experienced clinicians as subjects...

Objectives: Our research seeks to discover the deep structure of practitioner cognitive work. The purpose is to improve the capture, use, and sharing of information related to clinical planning and management at the clinical unit level, which shapes the unit's work and leads to success or failure of patient care.Methods: Field observation, informal...

With increasing attention to patient safety, hospitals and other clinical facilities are developing practice guidelines and protocols with the specific intent of reducing harm to patients. However, the introduction of these protocols can have unanticipated ...

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Studies of patient safety have identified gaps in current work including the need for research about communication and information sharing among healthcare providers. They have also encouraged the use of decision support tools to improve human performance. Distributed cognition is the shared awareness of goals, plans, and details that no single ind...

Communication was the most frequently cited cause of medication errors reported between 1995 and 2003. More detailed models of how communication breakdowns contribute to adverse events are needed to intervene to improve communication processes. We describe in detail an incident where an oncology fellow physician erroneously substituted the medicati...

In 1998, the Joint Commission on Accreditation of Healthcare Organizations identified important contributors to surgical site misidentification in the operating room (OR), including communication breakdown between surgical team members and the patient, availability of pertinent information, failure of OR policies and procedures, incomplete patient...

The advent of fast-acting drugs has made the infusion pump the most pervasive electronic medical device in the acute care (hospital) environment. Despite the importance of its correct operation, incident reports in the US Food and Drug Administration (FDA) database implicate interface programming as a significant aspect of adverse outcomes. This ar...

Adverse events, or accidents, in healthcare can have significant clinical outcomes including loss of property, health (morbidity), and life (mortality). Healthcare accidents have features that make post-event investigations particularly difficult. The investigation and analysis of medical accidents is intended to discover information that explains...

What role will human factors professionals play in healthcare 2020? Health systems throughout the world face a number of common pressures, related to demography, epidemiology, science and technology developments, and medical demand. In particular, while developments in technology do not just provide health care with new possibilities for human fact...

Over the last two decades there has been a growing recognition in the need for a systematic study of adverse events, errors and difficulties in health care. The systematic investigation of this topic and the resultant database have grown and diversified exponentially. We believe that the time has come to evaluate the achievements of this first wave...

Demands for acute care are uncertain and change frequently, while resources to meet them are constrained and subject to production pressure. To manage this conflict, the anesthesiology coordinator makes continual assessments and tradeoffs between and among patients and work groups. The complexity and uncertainty of the acute environment requires th...

Near-saturation conditions place a premium on practitioner cognition, especially on the ability to anticipate and prepare to cope with shifting clinical demands using available resources. The conditions are regarded as normal and practitioners become adept at coping with them. One coping strategy, bumping, is remarkable because it is ubiquitous and...

In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the imp...

Five panelists, playing active research roles in the Agency for Healthcare Research and Quality's patient safety research initiative, present their views on challenges to human factors research for enhancing patient safety. Bogner advocates a systems structure for linking the findings of various research projects so that the missing pieces of the p...

Following celebrated failures stakeholders begin to ask questions about how to improve the systems and processes they operate, manage or depend on. In this process it is easy to become stuck on the label ‘human error’ as if it were an explanation for what happened and as if such a diagnosis specified steps to improve. To guide stakeholders when cel...

1) Complex systems are intrinsically hazardous systems. All of the interesting systems (e.g. transportation, healthcare, power generation) are inherently and unavoidably hazardous by the own nature. The frequency of hazard exposure can sometimes be changed but the processes involved in the system are themselves intrinsically and irreducibly hazardo...

We describe an aviation scenario-based role-play simulation used to teach healthcare practitioners about barriers to learning from accidents. Participants searched for the causes of the crash in a scenario that encouraged a “garden path” explanation that the root cause was a risky decision to take off despite visible ice on the wings. During a debr...

Unexpected awareness is a rare but well-described complication of general anesthesia that has received increased scientific and media attention in the past few years. Transformed electroencephalogram monitors, such as the Bispectral Index monitor, have been advocated as tools to prevent unexpected recall. The authors conducted a power analysis to e...

Complex systems involve many gaps between people, stages, and processes. Analysis of accidents usually reveals the presence of many gaps, yet only rarely do gaps produce accidents. Safety is increased by understanding and reinforcing practitioners' normal ability to bridge gaps. This view contradicts the normal view that systems need to be isolated...

The "New Look" at Error The usual judgment after an accident is that human error was the cause. In other words, human error is the stopping point for an investigation and ends the learning process. However, just as recent celebrated accidents in medicine have directed attention to patient safety, previous highly visible accidents in other industrie...