Ross H. Ehrmantraut’s research while affiliated with University of Washington and other places

Effective anticipation is a fundamental characteristic of highly reliable organizations. In Rosen’s anticipatory theory of complex systems, all living systems and virtually all other complex systems require anticipatory models to maintain an organized state. This paper provides an overview of Rosen’s anticipatory theory of complex systems and presents a conceptual framework for applying this framework to improve safety and quality in healthcare. Organizational interventions based on this theory could include education of clinicians, patients, and families on how anticipatory complex systems function and improve safety in clinical environments, and systems interventions to promote optimal concordance between a team’s model of a clinical situation and the actual clinical situation. Enhanced general understandings of anticipatory complex systems and of their failure modes could help reduce communications failures that are a common cause of serious adverse events.

Performing patient care while wearing high-level personal protective equipment presents risks to healthcare providers. Our failure mode effects analysis identified 81 overall risks associated with providing hygienic care and linen change to a patient with continuous watery stool. Implementation of checklists and scheduled pauses could potentially mitigate 76.5% of all risks. Infect Control Hosp Epidemiol 2016;37:867–871