A propósito deste artigo, "Morreu de enfarte após três horas à espera nas urgências de Braga" recordei um capítulo que ando a ler, após recomendação de Karl Weick, "13 Operating at the Sharp End: The Complexity of Human Error" de Richard I. Cook e David D. Woods.
"Studies of incidents in medicine and other fields attribute most bad outcomes to a category of human performance labeled human error.
Generally, the "human" referred to when an incident is ascribed to human error is some individual or team of practitioners who work at what Reason calls the "sharp end" of the system.
Those at the "blunt end" of the system, to continue Reason's analogy, affect safety through their effect on the constraints and resources acting on the practitioners at the sharp end. The blunt end includes the managers, system architects, designers, and suppliers of technology. In medicine, the blunt end includes government regulators, hospital administrators, nursing managers, and insurance companies. In order to understand the sources of expertise and error at the sharp end, one must also examine this larger system to see how resources and constraints at the blunt end shape the behavior of sharp end practitioners."
Ao ler esta referência ao ""blunt end" of the system" fez-me recordar várias situações onde visualizei os trabalhadores sujeitos a objectivos conflituantes e a constrangimentos impostos pelo "blunt end" mas que nunca são referidos quando há um acidente. O capítulo uso três casos sobre os quais depois discorre.Um deles, se calhar é aplicável ao caso do hospital de Braga:
"On a weekend in a large tertiary care hospital, the anesthesiology team (consisting of four physicians of whom three are residents in training) was called on to perform anesthetics for an in vitro fertilization, a perforated viscus, reconstruction of an artery of the leg, and an appendectomy, in one building, and one exploratory laparotomy in another building. Each of these cases was an emergency, that is, a case that cannot be delayed for the regular daily operating room schedule. The exact sequence in which the cases were done depended on multiple factors. The situation was complicated by a demanding nurse who insisted that the exploratory laparotomy be done ahead of other cases. The nurse was only responsible for that single case; the operating room nurses and technicians for that case could not leave the hospital until the case had been completed. The surgeons complained that they were being delayed and their cases were increasing in urgency because of the passage of time. There were also some delays in preoperative preparation of some of the patients for surgery. In the primary operating room suites, the staff of nurses and technicians were only able to run two operating rooms simultaneously. The anesthesiologist in charge was under pressure to attempt to overlap portions of procedures by starting one case as another was finishing so as use the available resources maximally. The hospital also served as a major trauma center, which means that the team needed to be able to a start a large emergency case with minimal (less than 10 minutes) notice. In committing all of the residents to doing the waiting cases, the anesthesiologist in charge produced a situation in which there were no anesthetists available to start a major trauma case. There were no trauma cases, and all the surgeries were accomplished. Remarkably, the situation was so common in the institution that it was regarded by many as typical rather than exceptional."
Desta vez correu bem, mas podia ter corrido mal e a culpa era de quem?
"The conflicts and their resolution presented in Incident #3 and the trade-offs between highly unlikely but highly undesirable events and highly likely but less catastrophic ones are examples of strategic factors. People have to make trade-offs between different but interacting or conflicting goals, between values or costs placed on different possible outcomes or courses of action, and between the risks of different errors. People make these trade-offs when acting under uncertainty, risk, and the pressure of limited resources (e.g., time pressure, opportunity costs)."
É tão fácil e instintivo bater no bombo da festa... Não consigo esquecer aquele:
"O executivo regional está a oferecer-lhe uma recompensação de 215 mil euros, afirmando que é impossível “descobrir o culpado”.