Underground adaptations: Case studies from health care

Clinical work is accomplished by complex, highly distributed, joint cognitive systems, and involves high levels of uncertainty and ambiguity. Hospital emergency departments (EDs) in particular must adapt to uncertainty, ambiguity and change on a variety of different temporal scales. Many of these adaptations are unofficial, in part because they cannot be specified in advance and because the official models of healthcare work do not include or acknowledge them. This paper presents two case studies of reactive adaptation within the ED setting and uses these to explore their implications for cognitive engineering and design.