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System failure to blame for Walkerton, North Battleford outbreaks, says U of T study

better job of understanding how we build those high-level administrative and governmental systems to protect public health because we're not doing as good a job as we need to."

In a multi-layered system such as drinking water distribution, it's critical that information circulates to every level of the hierarchy to maximize co-ordination, Vicente says. The people at each level must be competent and they must have a commitment to public safety and clear guidelines with which to achieve that goal.

Guidelines, however, must be flexible. "You have to give people discretion to make decisions, but you also have to make sure that they're prepared or that they have the training and the knowledge to deal with these things."

At the same time, Vicente says, complex systems demand accountability-at all levels. "It's like an onion, and what happens is that people looking for a scapegoat usually stop at the first layer-at the front-line workers," he says. In almost every case, he explains, moving up the hierarchy reveals additional factors behind such system failures.

The research findings suggest ways that critical systems can alter their structure to improve error detection and reduce accidents and their consequences. "We need to recognize that when we deal with the issue of accountability and, more importantly, when we deal with the issue of design, we need to have in place positive, synchronized relationships so that we protect public health," Vicente says. "Humans are fallible and we have to accept and design for that, rather than expecting people to be perfect."

"We need to focus on managing risk better and designing socio-technical systems that protect, not threaten, public health. This applies to all critical safety systems, not just drinking water," says Vicente. "The problems are only going to get more severe as technological systems become more complex. We should all be concerned about this because these issues can threaten o
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Contact: Nicolle Wahl
nicolle.wahl@utoronto.ca
416-978-6974
University of Toronto
29-Apr-2003


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