|
 Sidney Dekker is a thought leader and a genius. He is Professor in the School of Humanities at Griffith University in Brisbane, Australia. He is also a commercial pilot. There is no one on the planet with a better understanding of the core issues of patient safety. Too bad not everyone is listening.
His book "Patient Safety" examines healthcare system complexity as the source of medical mistakes.
The doctor's work space is filled with ambiguity, uncertainty and moral choices. This work space is not guided by the healthcare organization's rules and regulations. It is not guided by best practices. It is guided by the local rationality of the work space.
A healthcare complex system with conflicting goals and outcomes focusing on better, faster and cheaper care is "drifting towards failure". This makes the system more prone to adverse events, as economic constraints and production needs increase.
The irony is that bad outcomes can arise even when everyone is doing good work and is following the rules. In complex situations, adverse events can arise without really bad assessments or bad decisions.
Adverse events are the result of structural interactive complexity and tight coupling within the system. The only way to reduce risk to is to reduce complexity. | 
Greetings! 
