Not Running a Hospital: How complex systems fail

A good discussion of healthcare and system failure, given the complexities involved. Main reasons:

  1. Complex systems contain changing mixtures of failures latent within them
  2. Complex systems run in degraded mode
  3. Post-accident attribution accident to a ‘root cause’ is fundamentally wrong
  4. Hindsight biases post-accident assessments of human performance
  5. Failure free operations require experience with failure

Not Running a Hospital: How complex systems fail.

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