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My Complex Hospital Stay

September 5, 2010

I spent some time last week in the hospital having a new foot built for me.  I don’t want to It's Happy Bunny!dwell too much on the details, but while I was in the hospital, in that drugged-induced stupor, I was thinking about “How Complex Systems Fail” by Richard Cook, MD.  After all he wrote that about the complex healthcare system, not Information Systems and I was hoping to get some pearl or enlightenment while laying there.   It’s been years since he wrote it and I was just hoping to see some little nugget that I  could take back to my day job.  However, what I found wasn’t illuminating at all, just more reinforcement of why that paper should be mandatory and memorized by all infosec people (and healthcare people).

I’m going to start off with my summary what I observed about healthcare that I think applies nicely over to infosec.

Focus on the Basics**

Citing from Cook’s paper, here’s the statement that pretty much summed up my stay:

Overt catastrophic failure occurs when small, apparently innocuous failures join to create opportunity for a systemic accident.

I had no catastrophic failure while staying in the hospital, but I had an endless supply of small failures and luckily no systemic accident.  Anyway, I love how that’s worded and I feel that may be addressed by focusing on the basics.  Any one part of a complex system may not be complex by itself, but become complex when they mix or intertwine with other parts of the complex system.  I think my care at the hospital (and information assets at work) could be better taken care of if we simply focus on the basics and work on doing them better.  I’m going to walk through two scenarios to help illustrate the point.

Scenario 1: Apply Ice

During my stay, advice from different “expert” practitioners would contradict others advice on moderately unimportant topics.  Things like how my boot is adjusted, benefits of elevation or even the purpose behind this or that drug.  I was able to easily understand this, I often find disagreement in advice from “experts” in our field.  But the separation between advice and practice is where I saw some interesting breakdown.

Nobody would say that icing wasn’t helpful.  It’s well understood that icing reduces swelling and would speed my recovery.  But it’s the details that diverge and how far away reality was that really surprised me.  One advice-giver was specific enough to say 15 minutes of every hour should be spent icing.  However, during my 2.5 days in the hospital I received 2 ice packs and both times I found it still under my leg with the ice melted hours afterwards.  Both times I had to pry the ice packs out from my leg and dump it onto the floor.

So how helpful is icing?  Like I said nobody would say it wasn’t helpful.  But according to their actions, it was less helpful than checking vitals and only slightly less helpful than emptying the bed pan.  Right?  We’ve got an imbalance in healthcare – a misperception on the cost vs. reward of certain activities.  We also have an imbalance in infosec.  We’ve got a misperception on the costs/rewards of certain technologies and are not doing things like checking logs as often as we should.  Like I said, let’s focus on the basics.

Scenario 2: Vital Signs

When I first arrived for surgery, they attached a blood pressure cuff on my arm and an oxygen monitor on my finger.  I was told these would stick with me and it was decided to attach these to my left arm after talking about my right-handedness.   During my stay, folks would come in at some interval (2-4 hours) and “check my vitals”.  At one point during the first night, when I was barely sensing reality, I woke up and realized that I was sleeping with two blood pressure cuffs and two oxygen monitors, one set on my left side and one on my right.   Once I pointed this out to the vital-checker, they removed both.  No, I don’t know why.  This is was Cook refers to as applying an “end-of-the-chain measure.”

How does this apply to infosec?  We need to be aware of misattribution of mistakes.  It’s easy to look at this and say that some nurse or assistant screwed up, and they should be scolded or publicly mocked or something.  But in reality we need to understand that this was a symptom.  We have to back up and truly figure out root cause, not enough time to communicate?  Is the culture anti-organizational-skills?  I’d like to say that I’ve never seen this in infosec, but I’d be lying.  We’ve all seen security controls installed/mandated that are redundant or worse, harmful (*cough* transparent encryption *cough*).

All in all, we have the tools and we have the ability.  I’d like to make a call out for avoiding catastrophic suckiness by simply focusing on the basics.   We need to focus on doing what we know how to do and we need to apply it coherently.  Pretty simple request I’d say.

**This post and summary is dedicated to my crappy and non-catastrophic stay at Regions Hospital, Saint Paul, MN.

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