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Perspectives on Safety > Interview
Unintended Consequences, June 2011
His seminal work in patient safety is generally credited with introducing the concept of unintended consequences.
Journal Article > Study
Cook RI, Woods DD. Hum Factors. 1996;38:593-613.
New technology continues to offer great advances and challenges. This article takes a detailed look at technology's impact on human performance by studying the implementation of a new physiological monitoring system for use in cardiac anesthesia. Discussion includes characteristics of the upgraded system, a process-tracing technique to examine the complex physician-computer interaction, and the problems that developed while in use. The authors introduce a number of new cognitive burdens that resulted and discuss how providers attempted to overcome these burdens within the framework of the new system. Though it represents one example, the rich discussion in this article applies to most new technology and the human factors that require it to function as technically designed.