A Sociotechnical Systems Analysis of the Toronto Sars Outbreak

Abstract

In February 2003, an outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto, Canada, resulted in 438 probable SARS cases, 44 deaths, and over 25,000 individuals quarantined. The purpose of this study was to investigate whether or not the predictions of Rasmussen's (1997) framework for risk management can explain how and why SARS was transmitted in Toronto. There are two propositions for this case study. First, multiple actions, decisions, and degrees of capability at all levels of the system are needed to explain how SARS was transmitted. Second, a lack of vertical integration between individuals and organizations explains why SARS was widely transmitted. Both propositions of this case study are supported by the data in the National Advisory Committee's report (Health Canada, 2003). Furthermore, almost all of the predictions made by Rasmussen's (1997) framework were confirmed by the events that transpired during SARS.