Although proponents of advanced information technology argue that automation can improve the reliability of health care delivery, the results of introducing new technology into complex systems are mixed. The new forms of failure that accompany automation challenge technical workers, often demanding novel approaches to recovering from failure and restoring system operations. We present a case where automation created a new form of failure that was not foreseen. In this case, human practitioners

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... ere the main source of robust and reliable health care delivery and were the primary agents in recovering from a life-threatening automation failure. The features of this case correspond closely to experience with new information technology in other domains and have implications for plans to improve patient safety using technology.