Joint Cognitive Systems

Being Bumpable 33

OBSERVATIONS ON THE INCIDENT

The administrative nurse’s attribution of the failure to “human error” on the part

of the patient care technician is remarkable. The focus on the most proximate flaw

in a long series of flaw s and faults as the “caus e” is the usual circumstance in

complex sys tem failures (Holln agel, 1993; Woods, et al., 199 4).

Interestingly, the event occasioned no deeper reflection on the part of the

admin istrator . No thought was given to the nature of ICU resource use or

scheduling, the roles of various parties in resolv ing resource conflicts , the impact of

operating a hospital at or near its theoretical cap acity, the po tentia l consequences of

the ex tra activities required of the many people in the ICU and ...