September 2017
Beginner to intermediate
292 pages
10h 27m
English
book
Behind Human Error, 2nd Edition
by David Woods, Sidney Dekker, Richard Cook, Leila Johannesen, Nadine Sarter
Content preview from Behind Human Error, 2nd Edition
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8GOAL CONFLICTS
STRATEGIC FACTORS
A third set of factors at work in distributed cognitive systems is strategic in nature. People have to make tradeoffs between different but interacting or conflicting goals, between values or costs placed on different possible outcomes or courses of action, or between the risks of different errors (Brown, 2005a, 2005b; Woods, 2006; Hollnagel, 2009). They must make these tradeoffs while facing uncertainty, risk, and the pressure of limited resources (e.g., time pressure; opportunity costs).
On a weekend in a large tertiary care hospital, the anesthesiology team (consisting of four physicians, three of whom are residents in training) was called on to perform anesthetics ...
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