Facilitating (and not Interfering with) Work System Resilience with New Technology

Traditionally, the negative unintended consequences of introducing new technologies into complex systems have not been explicitly assessed and mitigated. Recently, our understanding of how to identify, protect, and facilitate sources of resilience in a work system has advanced. In particular, there are lessons learned from two case studies of technologies: 1) voice loops, an auditory shared space that supported NASA Johnson communication and coordination, and 2) the introduction of bar coding in the medication administration process throughout the Veteran’s Health Administration. BCMA was designed to improve patient safety by reducing medication errors at the time of medication administration.

During and after implementation, there were unintended consequences on the ability of work systems to: 1) have a shared awareness of demands and deviations, 2) progressively respond to changing circumstances, 3) guide local control with policies and procedures, 4) flexibly adapt by reducing constraints on actions, and 5) coordinate across the system.