There has been a longstanding consensus that supporting error detection and recovery processes is critical for very high safety levels because it increases system resilience. System resilience is defined in Resilience Engineering as successful adaptation to variations, changes, and surprises by organizations, groups, or individuals. Cross-checking is a critical component of resilience because it can enable detection of erroneous assessments or actions while negative consequences can be mitigated or eliminated. Prior studies suggest that cross-checking where an additional human with a fresh perspective breaks fixations may be an effective strategy. Nevertheless, collaborative cross-checking remains a somewhat murky concept. In this paper, we describe in detail three healthcare incidents where collaborative cross-checking played a key role. Emerging patterns that provide opportunities for follow-on research are discussed.
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