Understanding Systems

Common Elements of System Failures and Medical Errors 

7 COMMON ELEMENTS OF SYSTEM FAILURES AND MEDICAL ERRORS 

A complex systan can break or fail and contribute to harm. 

A system or process may contain a latent defect before harm results. 

Humans develop behaviors to compensate for chronic system flaws. 

Current medical culture promotes individual accountability. 

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Bignell, V. and Fortune, J. 1992 Understanding Systems Failures. Manchester Manchester University Press. 

Before the analyst begins fault tree construction, it is necessary to document and understand System design,... 

Readers interested only in understanding systems incorporating fuel cells should proceed directly to the systems section. Section 9. 

In order to improve MD simulations, a number of specific areas should be addressed in the area of basic molecular dynamics theory. These include (1) development of full quantum mechanical calculations on complex molecules and more robust ways to incorporate quantum mechanical calculations within larger-scale classical mechanics or statistical mechanics approaches (2) development and refinement of transferable force fields between arbitrary atoms and molecules, which are necessary building blocks for MD simulations of general systems and (3) development of multiscale theories and techniques for understanding systems. Moreover, the community must develop toolkits that allow general users to perform such simulations. 

Documentation does not adequately reflect actual system (e.g., need to refer to supplementary change control records to understand system)... 

In summary of the discussion above, systemic analyses are needed to detect patterns across multiple scales in both the spatial (e.g., molecules to cells to tissues) and temporal (e.g., nanoseconds to hours to years) dimensions. Based on such understanding, systems and dynamical medicine can be developed with the emphasis on the whole systems that change over time to address the nonlinearity and interconnectivity toward a holistic and proactive care. Here, the word systems underscores the concept of holism, and the term of dynamical medicine highlights the variations with the interwoven and integration of the spatial and temporal scopes see Fig. 2). 

NMR spectroscopy, with its array of unique characteristics and capabilities, is playing a key role in the field of metabolomics. Specifically, the high reproducibility, excellent quantitation and ability to analyze intact samples offer numerous opportunities to understand systems biology, discover biomarkers,... 

Neuroscientists have always placed a strong emphais on understanding systems. As one new journal states in regard to its own scope ... 

Although systems in systems biology stems from systems sciences the goal is to understand systems in the colloquial sense. The detailed investigation of the components of the systems is the indispensable basis to reach this aim. 

Helping the analyst to understand system failures deductively... 

II. Exploiting Equipment Interactions The designer needs to consider total system interactions before finalizing scope for any equipment. Consider a revamp project with the main objective of increasing the duty of a column s feed pre-heater it will require assessment of the condenser s maximum capacity and top rectifying tray section. Simulation of the whole process is needed to understand system interactions. Lee et al. (2007) and Zhu (2014) described ethylene plant retrofit cases to emphasize the importance of system interactions in revamps. 

Chapter 10 addresses the assessment of the ability flight crew to cope with unsafe system failure conditions identified during the SSA process. As with Chapter 9, this chapter is written to assist the Safety Assessor in understanding system approaches to minimising crew error, the role of the operator, and how or when specialist Human Factors (HF) input and engagement might be required. 

The enterprise analyzes and prioritizes potential functional failure modes to define failure effects and identify the need for fault detection and recovery fimctions. Functional reliability models are established to support the analysis of system effectiveness for each operational scenario. Failures, which represent significant safety, performance, or environmental hazards, are modeled to completely understand system impacts. 

Aid contractors and contract administrators in understanding system safety requirements. 

Kasser, J. E. (2007). A Framework for Understanding Systems Engineering. 1st ed. Bedfordshire, England BookSurge Publishing. 

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