ABSTRACT
Introduction Cross-checking is key to detecting erroneous assessments or actions and subsequently aiding in the recovery processes of a system. The ability to minimize or eliminate the negative consequences of these erroneous actions is a marker of system resilience. A first general definition of cross-checking is the examination and questioning of information occurring among various agents of the working system. In a complex socio-technical system, cross-checking can happen at different levels: among peers, between practitioners at different steps of the process, between human and automated agents. The Beatson report (Johnston, 2006) focuses on the first level of the analysis of a radiotherapy adverse event. In this case, we suggest that system brittleness stems partly from insufficient or ineffective cross-checking opportunities (Patterson et al., 2007). These missed opportunities were particularly hard to recognize due to a context of rapid and recent technological and procedural changes. The purpose of this chapter is to further explore a particular dimension of system resilience, especially in the Beatson case, in order to refine the definition of cross-checking proposed above.
