Automation, interaction, complexity, and failure: A case study

Although proponents of advanced information technology argue that automation can improve the reliability of health care delivery, the results of introducing new technology into complex systems are mixed. The complexity of the health care workplace creates vulnerabilities and problems for system designers. In particular, some forms of failure emerge from the interactions of independently designed and implemented components. We present a case study of such an emergent, unforeseen failure and use it to illustrate some of the problems facing designers of applications in health care.