ABSTRACT
A set of three known patterns of adaptive system breakdown and their known countermeasures were used in designing the processes, structures, and interventions of an implementation team. This team was tasked with supporting the patient care processes of detecting and responding to critical patient events. These system breakdown patterns focused the efforts of the implementation team on 1) support of clinicians’ anticipation of critical patient events, 2) identification of alarm system vulnerabilities that inhibited anticipation and response to these events, 3) organizational vulnerabilities that distracted from or diluted the efforts of the implementation team, 4) multiple competing goals and perspectives within the implementation team that resulted in counterproductive solutions, 5) detection and correction of incorrect psychological models of alarm response, and 6) detection and correction of incorrect conceptions of how clinical work was being performed. After multiple iterations, these foci resulted in the successful implementation of interventions that improved patient care. This serves as a powerful illustration that implementation systems, too, are subject to the laws of the adaptive universe. Using these laws in our implementation and organizational designs will support successful implementations. Ignoring these laws will likely result in predictable but unforeseen consequences.
