Collaborative cross-checking to enhance resilience |
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| Authors: | Emily S Patterson David D Woods Richard I Cook Marta L Render |
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| Affiliation: | (1) VA Getting at Patient Safety (GAPS) Center, Cincinnati VAMC, Institute for Ergonomics, Ohio State University, 210 Baker Systems, 1971 Neil Avenue, Columbus, OH 43210, USA;(2) Institute for Ergonomics, Ohio State University, 210 Baker Systems, 1971 Neil Avenue, Columbus, OH 43210, USA;(3) Cognitive Technologies Laboratory, Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Avenue MC4028, Chicago, IL 60637, USA;(4) Department of Internal Medicine, VA Getting at Patient Safety (GAPS) Center, Cincinnati VAMC, University of Cincinnati, 3200 Vine Street, Cincinnati, OH 45220, USA |
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| Abstract: | Resilience, the ability to adapt or absorb disturbance, disruption, and change, may be increased by team processes in a complex,
socio-technical system. In particular, collaborative cross-checking is a strategy where at least two individuals or groups
with different perspectives examine the others’ assumptions and/or actions to assess validity or accuracy. With this strategy,
erroneous assessments or actions can be detected quickly enough to mitigate or eliminate negative consequences. In this paper,
we seek to add to the understanding of the elements that are needed in effective cross-checking and the limitations of the
strategy. We define collaborative cross-checking, describe in detail three healthcare incidents where collaborative cross-checks
played a key role, and discuss the implications of emerging patterns. |
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