Systems seem to run at the very edge of failure much of the time. The combination of high workload, limited resources, pressure for additional features and capability, and inherent software, hardware, and network fragility is a noxious kettle of stuff always about to boil over in the form of outages, degraded response, or functional breakdowns. For insiders the surprising thing about our systems is not that they fail so often but that they fail so rarely! This good performance in the face of adverse conditions is called resilience. An important conclusion from resilience studies is that it depends critically on human operators and their ability to anticipate and monitor the system, react to threats, and sacrifice some goals to protect others. This talk will introduce resilience and a model of system dynamics useful in analyzing failed and successful event management and offer an explanation for why our systems run at the edge of failure.
Dr. Richard Cook is the Professor of Healthcare Systems Safety at the Kungliga Techniska Hogskolan (the Royal Institute of Technology) in Stockholm, Sweden. He is a practicing physician, researcher and educator. Dr Cook received his BA degree from Lawrence University in Appleton, Wisconsin shortly after the invention of the telephone. After a misspent career in the computer industry he went to medical school at the University of Cincinnati and, much to the surprise of the faculty there, was awarded the MD degree in 1986. He wasted a lot of time and effort in various residency and fellowship programs but was finally able to complete training as an anesthesiologist. Between 1994 and 2012 he gave anesthesia to patients, tried to teach medical students and residents, and studied safety and complex systems at the University of Chicago. He was such a strong, public critic of IT application safety in healthcare and other domains that he had to leave the country. In 2012 he moved to Sweden to become the first (and, probably, the last) healthcare system safety professor in that country. He does not perform any paid expert testimony regarding his research primarily because he is never asked to do so. Dr. Cook has been known to say to audiences, “Although I am often invited to speak, I am seldom invited back.” His appearance at a second Velocity conference is an anomaly that has not been explained.
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