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 Ричард Кук. Как ломаются сложные системы
Перевод Романа Журавлева, Клеверикс

How Complex Systems Fail now available in Russian.
Roman Jouralev has kindly translated the short paper How Complex Systems Fail into Russian and posted it in two locations: at www.cleverics.ru and www.itsmforum.ru. These websites are focused on software and general IT.

Themes in
Healthcare Cognition

Lost in Menuspace: How practitioners cope with infusion device complexity

Mode Error: Why users misunderstand modes of operation

Making IT a Team Player: How IT needs to work in healthcare.  Includes research methods video

Technomania: Bruce McCall's "Getting Started"

Adverse Event Investigation: Medical Event Data Collection and Analysis Service (MEDCAS)

Endoscope Compatibility Popular scope models/ sizes, with smallest ET ID's and lumen

Important meeting dates:



CTL director dissents from IOM report on HIT and patient safety.
Richard I Cook, Director of CTL, was a member of an Institute of Medicine committee examining the impact of health IT on patient safety.  He wrote a dissenting opinion which was published along with the report on November 8, 2011. The full report is available on the National Academy of Sciences website for free download.

At issue is the safety of current health IT.  It is clear that current health IT, particularly electronic medical records (EMRs) used in many hospitals and clinics, poses a serious threat to patient safety.  The use of these systems has led to harm to patients as demonstrated by the case cited in the dissent.  The failure by the HIT industry and the government to anticipate, acknowledge, and address the safety of these medical devices has crippled the development of effective health IT. This makes it virtually certain that U.S. healthcare will fail to acquire the economic and safety benefits of health IT for the foreseeable future.

The CTL website publications collectively address the underlying problem with current generation health IT and provide a roadmap for understanding technical work and developing effective, useful HIT that improves patient safety.

Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method
A recent article by Greenhalgh et al. provides a detailed review of the evidence regarding the value of electronic patient records. It is available directly from the Milbank Quarterly website.

Medicare Payment Changes
Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates (CMS-1390-F), published 19 August 2008, describes adjustments to 2009 Medicare compensation including acute care organizations that are teaching hospitals, serve low income patients, and handle unusually costly "outlier" cases.  (more…)

Building Resilient Complex Systems
Ashgate Publishing's Resilience Engineering Perspectives Series now includes Remaining Sensitive to the Possibility of Failure, which compiles papers from the November 2007 2nd Symposium on Resilience Engineering in Juan-Les-Pins France. These newly-evolving concepts of resilience and resilience engineering define "success" based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Resilience Engineering: Concepts and Precepts was the first volume to explore this groundbreaking new development in safety and risk management.
     The 3rd International Symposium on Resilience Engineering, held in November 2008, featured recent research and writing on resilience and engineering resilient systems.

Strasbourg Keynote Probes Adverse Event Investigation
CTL's Richard Cook gave one of two main keynote presentations at the International Conference on Health Systems Ergonomics and Patient Safety in Strasbourg, France on June 25th, 2008.  His presentation, "What are we missing?  Results of MEDCAS, the National Healthcare Safety Board Demonstration Project" described what a team of technically-qualified independent investigators can learn about adverse events that in-house investigations miss. His message was based on the CTL's recent "Medical Event Data Collection and Analysis Service" project funded by the VHA Health Foundation and the U.S. Food and Drug Administration.

Improving Healthcare Team Communication
CTL's Christopher Nemeth edited the recent Ashgate Publishing release Improving Healthcare Team Communication that features the work of leading researchers in healthcare communication. Their insights from 'sharp end' operator research in high-hazard sectors shed light on the performance of cognitive tasks in groups and across healthcare organizations. 
    "Here a cluster of the world's experts extract lessons from both domains that those who seek to improve patient safety will find fascinating and useful." --Lucian L. Leape, MD, Harvard School of Public Health, USA

Bewildered by medical equipment interfaces? You're not alone! Bruce McCall introduces the latest gizmo designed to maximize your performance through information technology. (more...)

Recent Publications


Before I forget: How clinicians cope with uncertainty through ICU sign-outs
Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Practitioners
   [2006] (7,702 KB)
Case 2-2006: Catastrophic cardiovascular collapse during carotid endarterectomy
   [2006] (469 KB)
Clinical human-centered research: Bridging social science and engineering
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
   [2006] (2.21 MB)
Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents
   [2006] (2.79 MB)
Don't Close the Valve! The Effect of Closing the Valve on Ventilation in Patients Undergoing ECT
   [2006] (49 KB)
Hobson’s choices: Matching and mismatching in transplantation work processes
   [2006] (1.32 MB)
Incidents - Markers of Resilience or Brittleness?
   [2006] (2.21 MB)
Learning from investigation: Experience with understanding healthcare adverse events
   [2006] (145 KB)
Taking Things in One's Stride: Cognitive Features of Two Resilient Preformances
   [2006] (4.74 MB)
The Ambu Bag is Superior to the Mapleson D for Hyperventilating Electroconvulsive Therapy Patients
   [2006] (54 KB)
Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology
   [2006] (138 KB)
Time to Get Off This Pig's Back? The Human Factors Aspects of the Mismatch Between Device and Real-World Knowledge in the Health Care Environment
   [2006] (356 KB)
To err is not always human


A Brief Look at Gaps in the Continuity of Care and how Practitioners Compensate for Them
   [2005] (109 KB)
A brief look at Going Solid and the Dynamics of Safety
   [2005] (84 KB)
A Brief Look at the New Look in Complex System Failure, Error, Safety & Resilience
   [2005] (929 KB)
Above Board: Issues in Medical Account Investigation and Analysis
   [2005] (339 KB)
Automation, interaction, complexity and failure: A case study
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
   [2005] (164 KB)
Central Venous Oxygen Saturation Does Not Correlate with Serum Lactate in Patients with Cardiogenic Shock after Cardiac Surgery
   [2005] (39 KB)
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
   [2005] (644 KB)
Cognitive Artifacts in Complex Work.
   [2005] (1.52 MB)
Collaborative Cross-Checking to Enhance Resilience
   [2005] (66 KB)
Con: Tight Perioperative Glycemic Control: Poorly Supported and Risky
   [2005] (53 KB)
Discovering variability in infusion device flow rates by automated gravimetric measurement
   [2005] (446 KB)
Distributed cognition: how hand-off communication actually works
   [2005] (1.01 MB)
Failure in context: linking observed behavior to cognition, tasks, and adverse events
   [2005] (724 KB)
Getting to the Point: Developing IT for the Sharp End of Healthcare
   [2005] (643 KB)
Going Solid: A Model of System Dynamics and Consequences for Patient Safety
   [2005] (174 KB)
Health Care Forensics.
   [2005] (12.5 MB)
Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT
   [2005] (84 KB)
Large Scale Coordination: The Study of Groups at Work
   [2005] (142 KB)
Lessons from the War on Cancer
   [2005] (1635 KB)
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
   [2005] (361 KB)
Making Sense of Risks: A Field Study in an Intensive Care Unit
   [2005] (4992 KB)
Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
   [2005] (.97 MB)
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
   [2005] (255 KB)
The Role of Automation in Complex System Failures
   [2005] (101 KB)
Thinking About Accidents and Systems
   [2005] (345 KB)
Toward a Theory of Patient Safety - Lessons From the First Decade
   [2005] (398 KB)

for publications from previous years click here
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