Cognition, Technology & Work

, Volume 9, Issue 3, pp 155–162

Collaborative cross-checking to enhance resilience

  • Emily S. Patterson
  • David D. Woods
  • Richard I. Cook
  • Marta L. Render
Original Article


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.


  1. Behara R, Wears R, Perry S, Eisenberg E, Murphy L, Vanderhoef M, Shapiro M, Beach C, Croskerry P, Cosby K (2005) A conceptual framework for studying the safety of transitions in emergency care. Adv Patient Safety 2309–2321Google Scholar
  2. Brown JP (2005) Ethical dilemmas in healthcare. In: Patankar M, Brown JP, Treadwell MD (eds) Ethics in safety. Cases from aviation, healthcare, and occupational and environmental health. Ashgate, Burlington VTGoogle Scholar
  3. Carthy J, de Leval MR, Reason JT (2001) Institutional resilience in healthcare systems. Qual Health Care 10:29–32CrossRefGoogle Scholar
  4. Cook RI, Render ML, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. Br Med J 320:791–794CrossRefGoogle Scholar
  5. Cook RI, Rasmussen J (2005) Going solid: a model of system dynamics and consequences for patient safety. Qual Safety Health Care 14:130–134CrossRefGoogle Scholar
  6. de Leval MR, Carthey J, Wright DJ, Farewell VT, Reason JT (2000). Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg 119(4 Pt 1):661–672Google Scholar
  7. Cooper JB, Long CD, Newbower RS, et al (1982) Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 56(6):456–461CrossRefGoogle Scholar
  8. Dekker SWA (2005) Ten questions about human error: a new view of human factors and system safety. Lawrence Erlbaum, Hillsdale, NJGoogle Scholar
  9. Erev I, Gopher D, Itkin R, Greenshpan Y (1995) Toward a generalization of signal detection theory to n-person games: the example of two person safety problem. J Math Psychol 39:360–376MATHCrossRefGoogle Scholar
  10. Guerlain S, Smith PJ, Obradovich JH, Rudmann S, Strohm P, Smith J, Svirbely J (1996) Dealing with brittleness in the design of expert systems for immunohematology. Immunohematology 12:101–107Google Scholar
  11. Hollnagel E (2004) Barriers and accident prevention. Ashgate Publishing, AldershotGoogle Scholar
  12. Hollnagel E, Woods DD, Leveson N (2006) Resilience engineering: concepts and precepts. Ashgate Publishing, AldershotGoogle Scholar
  13. Klein GA, Calderwood R, MacGregor D (1989) Critical decision method for eliciting knowledge. IEEE Trans Syst Man Cybern 19(3):462–472CrossRefGoogle Scholar
  14. Klein G (2006) The strengths and limitations of teams for detecting problems. Cogn Technol Work (in press)Google Scholar
  15. Klein G, Pliske R, Crandall B, Woods D (2005) Problem detection. Cogn Technol Work 7(1):14–28CrossRefGoogle Scholar
  16. Leape L, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW (1999) Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 282:267–270CrossRefGoogle Scholar
  17. Miller A, Xiao Y (2006) Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre. Cogn Technol Work (in press)Google Scholar
  18. Patterson ES, Cook RI, Render ML (2002) Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc 9(5):540–553CrossRefGoogle Scholar
  19. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO (2004) Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 16(2):125–132CrossRefGoogle Scholar
  20. Patterson ES, Cook RI, Woods DD, Render ML (2004) Examining the complexity behind a medication error: generic patterns in communication. IEEE Trans Syst Man Cybern Part A 34(6):749–756CrossRefGoogle Scholar
  21. Rasmussen J (1990) The role of error in organizing behavior. Ergonomics 33:1185–1199CrossRefGoogle Scholar
  22. Sarter N (2000) Error types and related error detection mechanisms in the aviation domain: an analysis of aviation safety reporting system incident reports. Int J Aviat Psychol 10(2):189–195CrossRefGoogle Scholar
  23. Sutcliffe K, Vogus T (2003) Organizing for resilience. In: Cameron KS, Dutton IE, Quinn RE (eds) Positive organizational scholarship. Berrett-Koehler, San Francisco, pp 94–110Google Scholar
  24. Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E (2002) System innovation: concord hospital. Jt Comm J Qual Improv 28(12):666–672Google Scholar
  25. Weick KE, Sutcliffe KM, Obstfeld D (1999) Organizing for high reliability: processes of collective mindfulness. Res Org Behav 21:13–81Google Scholar
  26. Westrum R (2006) A typology of resilience situations. In: Hollnagel E, Woods DD, Leveson N (eds) Resilience engineering. Ashgate, Aldershott, pp 55–67Google Scholar
  27. Williams PS (1986) Processing demands, training, and the vigilance decrement. Hum Factors 28:567–579Google Scholar
  28. Woods DD (2005) Creating foresight: lessons for resilience from Columbia. In: Starbuck WH, Farjoun M (eds) Organization at the limit: NASA and the Columbia disaster. BlackwellGoogle Scholar
  29. Woods DD, Shattuck LG (2000) Distant supervision—local action given the potential for surprise. Cogn Technol Work 2:86–96CrossRefGoogle Scholar
  30. Woods DD, O’Brien J, Hanes LF (1987) Human factors challenges in process control: the case of nuclear power plants. In: Salvendy G (ed) Handbook of human factors/ergonomics. Wiley, New YorkGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2006

Authors and Affiliations

  • Emily S. Patterson
    • 1
  • David D. Woods
    • 2
  • Richard I. Cook
    • 3
  • Marta L. Render
    • 4
  1. 1.VA Getting at Patient Safety (GAPS) Center, Cincinnati VAMC, Institute for ErgonomicsOhio State UniversityColumbusUSA
  2. 2.Institute for ErgonomicsOhio State UniversityColumbusUSA
  3. 3.Cognitive Technologies Laboratory, Department of Anesthesia and Critical CareUniversity of ChicagoChicagoUSA
  4. 4.Department of Internal Medicine, VA Getting at Patient Safety (GAPS) Center, Cincinnati VAMCUniversity of CincinnatiCincinnatiUSA

Personalised recommendations