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espanolEn 1984, Perrow expone su teoria de “Accidentes normales”y habla de complejidad de interaccion, dondelas catastrofes son inevitables en sistemas complejosacoplados firmemente. Predice que van a ocurrir fallasde muchas maneras impredecibles. La falla de uncomponente puede tener multiples efectos “rio abajo”(downstream). En estos sistemas, hay pocas posibilidadesde substituir o reasignar personal debido a laaltisima especializacion, contacto personal cerrado ypoca comprension de algunos procesos. Hay un puntoen la organizacion, el cual, una vez traspasado, resultaen el colapso del nivel siguiente. Al llegar a el, puedeocurrir un cambio que en si mismo es insignificante,pero que en el sistema puede llevar a una transformacionmasiva, rapida y catastrofica. (1) Ejemplos de estoserian accidentes de aviacion o pacientes complicadosque sufren ciclos de errores o de CEC, olvidando darheparina para iniciarla. El analisis sistemico de los accidentesmuestra que estos resultan de una alineacionde condiciones y sucesos, cada uno de los cuales es necesario,pero ninguno solo es suficiente para provocarlo. EnglishIn 1984, Perrow states his theory of “Normal accidents”and describes complex interactions, where catastrophesare unavoidable in tightly coupled complexsystems. He predicts that failures will occur in manyunpredictable ways. The failure of a component mayhave multiple downstream effects. In these systemsthere are few possibilities of substituting or reassigningpersonnel due to their high specialization, closedpersonal contact and scarce understanding of someprocesses. There is a point in the organization, which,once transgressed, results in the collapse of the followinglevel. When this is reached, a change, insignificantin itself, may occur, but which may lead to amassive, fast and catastrophic transformation of thesystem. (1) Aviation accidents or complicated patientswho suffer cycles of errors or cardiopulmonary bypasserrors (CPB) caused by forgetting heparin administrationbefore its initiation, are examples of this typeof accidents. The integral analysis of accidents showsthat these result from the alignment of conditions andevents, each of which is necessary, but none alone isenough to provoke it.

Aviation and Cardiac Surgery: What Can Be Tranferred from One to the Other To Improve Safety?