ABSTRACT
Delivering safe medical care is critically dependent upon the clinician’s ability to obtain and synthesize information to make appropriate clinical decisions. The preceding chapters have introduced several foundational concepts that shed light on designing this complicated process to work reliabilty and the potential it has for positive impact on clinical care when it works well. This chapter more specifically explores – breakdowns in the evidence, information and knowledge (EI&K) pathway, and the potential for disastrous consequences that can ensue. Analyzing these breakdowns is essential to understanding what went wrong and why, and is the first step in re-designing systems and processes to prevent similar breakdowns in the future.
