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Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety


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... that the factors would “inevitably” lead to an accident. Hindsight bias remains the primary obstacle to accident investigation, especially when expert human performance is involved." In great short paper:

The best thing I’ve read this year: How Complex Systems Fail by Richard Cook https://t.co/OLVJM6KBzL This is a ~3 page paper with 18 observations on system failure & the role of humans in it. Substitute "systems" with "teams" or "companies" & it's still fairly relevant....

The best thing I’ve read this year: How Complex Systems Fail by Richard Cook https://t.co/OLVJM6KBzL This is a ~3 page paper with 18 observations on system failure & the role of humans in it. Substitute "systems" with "teams" or "companies" & it's still fairly relevant.

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