Failure to THRIVE.

tive way of looking at incidents and accidents arising in high-risk environments [3]. He proposed that we look at work in terms of coupling and complexity of interactions. This approach has been applied to anaesthetic practice to break the chain of accident evolution [4]. The headline message from this is that when coupling is tight and complexity is high, the risk of a bad outcome is increased. We suggest that appreciation of coupling and complexity may be used for clinical decision-making in a simple way. We propose that two questions are asked. First, how complex is the situation? A simple count of complexity factors is done. Since a count does not bear linear relationship to risk, a higher count should be treated with due concern. Quite simply, more factors means a bigger chance of emergent outcome and this carries far more risk. Second, with appreciation of the primacy of oxygenation [5], how tight are the couplings between action and outcome? This is a measure of commitment. Whatever airway scheme is considered, if the risk of hypoxia is tightly coupled to any proposed action, risk becomes high, and measures to loosen this coupling should be sought. We appreciate that this approach is essentially approximate, but we think it’s worthwhile. If there are sufficient warnings, a variety of proactive measures are needed, with mobilisation of resources, particularly personnel and equipment. A key consideration should be that when coupling is tight and complexity count is high, the patient’s airway should probably be secured awake whenever this is reasonable.