Approaching the hotspot increases the impact: Process breakdowns in a safety-critical system-of-systems

This paper reports a study that examines process breakdowns in the operations of a hospital's surgical unit. We find a correlation between the stage in the surgical process in which a breakdown is detected and the breakdown impact. We derive a model of the relationship between breakdown detection, impact, and safety within the surgical domain. We discuss the practical implications for targeted breakdown prevention and detection within the process, and the latent effects on safety.