Failures of healthcare systems

This paper is concerned with the dependability aspects of a number of healthcare systems that have ‘failed ’ in various ways. It examines the different classes of healthcare systems and potential types of failures. The case studies covered in the paper include The London Ambulance Dispatching System[Finkelstein, 1993], Therac-25[Leveson, 1995], Anaesthetist ’ equipment, Respiration Monitoring Device and various accounts of Electronic Hospital Records[Heath, 1996]. The focus of the paper is on the aspects of dependability that could have been improved during the Design stage. The paper concludes with an outline of some key lessons for Design and examines the possibility of situation knowledge being made available to designers, by means of a multi-media database, to reduce the potential failures of a system. This paper contributes to the notion of ‘Design as critique’ which requires understanding the dangers and possibilities of formal tools, searching for ways in they may become, “powerful yet fragile instruments of change."(Berg