taking such a view challenges many widespread practices found in health IT vendors and health care-providing organizations. Vendors often focus on the role of technology when safety is compromised, and they pledge to fix any technology problems thus found without addressing the human- interaction component in the overall functioning of the technology as an inextricable component of health IT as a clinical tool. Because complex systems almost always fail in complex ways (a point noted in safety examinations in other fields7), health care organizations must focus on identifying the conditions and factors that contribute to safety compromises. They must pledge to address these conditions and factors in ways that reduce the likelihood of unsafe events rather than superficially focusing only on single root causes. Failure to acknowledge that technology-related problems that are encountered are a product of larger systems-based issues will result in the implementation of countermeasures that will fall far short with regard to the reduction of risk to the patient.

The fact that a sociotechnical system has multiple components that interact with each other in unpredictable ways means that an isolated examination of any one of these components will not yield many reliable insights into the behavior of the examined component as it operates in actual practice. This point has implications for technology developers in particular, who must develop products that can fit well into the operational practices and workflow (which are usually nonlinear) of many different health care organizations. The next chapter suggests various levers with which to improve safety.

REFERENCES

Baker, J. A. 2007. The report of the BP U.S. Refineries Independent Safety Review Panel. http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/SP/STAGING/local_assets/assets/pdfs/Baker_panel_report.pdf (accessed September 28, 2011).

Cohen, T., B. Blatter, C. Almeida, and V. L. Patel. 2007. Reevaluating recovery: Perceived violations and preemptive interventions on emergency psychiatry rounds. Journal of the American Medical Informatics Association 14(3):312-319.

Fox, W. M. 1995. Sociotechnical system principles and guidelines: Past and present. Journal of Applied Behavioral Science 31(1):91-105.

Global Aviation Information Network Working Group E. 2004. A roadmap to a just culture: Enhancing the safety environment. http://204.108.6.79/products/documents/roadmap%20to%20a%20just%20culture.pdf (accessed August 9, 2011).

Harrison, M. I., R. Koppel, and S. Bar-Lev. 2007. Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. Journal of the American Medical Informatics Association 14(5):542-549.

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7 This point was noted in the report of the Board investigating the Shuttle Columbia disaster (http://spaceflightnow.com/columbia/report/006boardstatement.html) and in the investigation of the Deepwater oil rig explosion (http://www.deepwaterinvestigation.com/go/doc/3043/1193483/).



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