The Nemesis Effect in Healthcare: Complexity, Artificial Intelligence and Patient Safety
Main Article Content
Abstract
The Nemesis Effect occurs when a clinical intervention increases the likelihood of the adverse outcome it was intended to avoid, or has other perverse effects that vitiate its benefits. The effect arises from the natural tendency of a complex adaptive system (such as healthcare) toward increased ‘entropy’— that is, toward greater disorder — mediated through both the complex interconnectedness of its components and a relative inability of well-meaning human agents to see ‘the bigger picture’ when implementing powerful policies and technologies. To illustrate the concept, several examples are cited from modern medical practice: the rise of multidrug-resistant organisms, the unintended effects of the European Working Time Directive, and the deskilling impact of certain novel technologies in surgery and anaesthesia. The potential nemesis effects of artificial intelligence (AI) on clinical practice are then discussed, together with possible seeds of remedy through a human factors/ergonomics approach to healthcare governance and clinical training. Good clinical governance can be seen as a way of maintaining a state of ‘negative entropy’ needed to keep a ‘living’ system safe, stable and functional. This requires the ongoing expenditure of energy and effort, as well as the adoption of a broader sociotechnical perspective.
Keywords:
Nemesis, sociotechnical, complexity, VUCA, artificial intelligence, deskilling, human factors, ergonomics
Article Details
How to Cite
PRINEAS, Stavros.
The Nemesis Effect in Healthcare: Complexity, Artificial Intelligence and Patient Safety.
Medical Research Archives, [S.l.], v. 14, n. 1, jan. 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7124>. Date accessed: 03 feb. 2026.
doi: https://doi.org/10.18103/mra.v14i1.7124.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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4 Pandit M. (2021) Critical factors for successful management of VUCA times. BMJ Leader 5:121-123
5 Cernega A, Nicolescu DN, Imre MM, Totan AR, Arsene AL, Serban RS, Perpelea A-C, Nedea M-I, Pituru S-M. (2024) Volatility, Uncertainty, Complexity, and Ambiguity (VUCA) in Healthcare. Healthcare (Basel) 12(7):773. doi:10.3390/healthcare12070773
6 Kurtz CF, Snowden DJ. (2003) The new dynamics of strategy: Sense-making in a complex and complicated world. IBM Systems J 42(3):462-83.
7 Snowden D, Rancati A. (2021) Managing Complexity (and Chaos) in Times of Crisis: A Field Guide for Decision Makers Inspired by the Cynefin Framework. Publications Office of the European Union Pubs. Available at https://publications.jrc.ec.europa.eu/repository/handle/JRC123629 (accessed 1 Dec 2025)
8 Braithwaite J, Clay-Williams R et al. (2013) Health Care as a Complex Adaptive System. In: Resilient Health Care (Ashgate Pubs., Farnham UK). 57-73
9 Illich, I (1976). Limits to Medicine - Medical Nemesis: The Expropriation of Health. Marion Boyars Pub. London. passim
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14 Frosh A. (1999). Prions and the ENT surgeon. J Laryngol Otol 113:1064-7.
15 Frosh A, Joyce R, Johnson A. (2001) Iatrogenic vCJD from surgical instruments. BMJ 322(7302):1558–1559. doi: 10.1136/bmj.322.7302.1558
16 Re-introduction of reusable instruments for tonsil surgery. Department of Health (UK) Press Release December 14, 2001. Available through UK National Archives website at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4011629 (accessed 13 Nov 2025)
17 European Commission. (2003) Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time. Official Journal L 299, 18/11/2003. 9–19. Available at https://eur-lex.europa.eu/eli/dir/2003/88/oj/eng accessed 13 Jul 2025
18 Royal College of Surgeons of England. (2014) Taskforce report on the impact of the European Working Time Directive. Available at https://www.rcseng.ac.uk/-/media/Files/RCS/Standards-and-research/Standards-and-policy/Service-standards/Workforce/wtdtaskforcereport2014.pdf (accessed 01 August 2025)
19 Anantharachagan A, Ohja K. (2011) Working time directive and its impact on training. Obs Gyn Rep Med 21(3):91-93 doi: 10.1016/j.ogrm.2011.01.005
20 Axelrod L, Shah DJ, Jena AB (2013). The European Working Time Directive: An Uncontrolled Experiment in Medical Care and Education. JAMA 309(5): 447-8. doi:10.1001/jama.2012.148065
21 Alkatout I, Mechler U et al. (2021) The Development of Laparoscopy: an Overview. Front Surg 8:79942 doi: 10.3389/fsurg.2021.799442
22 Patil M Jr, Gharde P, Reddy K, Nayak K. (2024) Comparative Analysis of Laparoscopic Versus Open Procedures in Specific General Surgical Interventions. Cureus 16(2):e54433. doi: 10.7759/cureus.54433
23 Burgdorf SK, Rosenberg J (2012) Short Hospital Stay after Laparoscopic Colorectal Surgery without Fast Track. Minim Invasive Surg 2012:260273. doi: 10.1155/2012/260273
24 Schildberg C, Weber U, König V, Linnartz M, Heisler S, Hafkesbrink J, Fricke M, Mantke R. (2025) Laparoscopic appendectomy as the gold standard: What role remains for open surgery, conversion, and disease severity? An analysis of 32,000 cases with appendicitis in Germany. World J Emerg Surg 20(1):53
25 Patil M, Gharde P, Reddy K, Nayak K. (2024) Comparative Analysis of Laparoscopic Versus Open Procedures in Specific General Surgical Interventions. Cureus 16(2):e54433. doi: 10.7759/cureus.54433
26 Cheung FY, Bretherton K, Wong N. (2022) SP7.7 Open Appendicectomy Confidence and Experience Study (OACES): a multicentre survey of UK non-consultant grade surgeons BJS 105(9):znac247.080. doi: 10.1093/bjs/ znac247.080
27 Ring L, Landau R, Delgado C. (2021). The Current Role of General Anaesthesia for Cesarean Delivery. Curr Anaesthesiol Rep 11(1):18-27. doi: 10.1007/s40140-021-00437-6
28 Johnson RV Lyons GR et al. (2000) Training in obstetric general anaesthesia: a vanishing art? Anaesthesia 55(2): 179-83 doi: 10.1046/j.1365-2044.2000.055002179.x
29 Searle RD, Lyons G. (2008) Vanishing experience in training for obstetric general anaesthesia: an observational study. Int J Obstet Anaesthesiol 17(3):233-7. doi: 10.1016/j.ijoa.2008.01.007
30 Palanisamy A, Mitani AA, Tsen LC. (2011) General anaesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anaesthesiol 20(1): 10-16. doi:10.1016/j.ijoa.2010.07.002
31 Brain AI. (1983) The Laryngeal Mask Airway – a new concept in airway management. BJA 55(8):801-5 doi: 10.1093/bja/55.8.801
32 Brimacombe JR, Berry AM, Brain AIJ. (1995). The laryngeal mask airway. Anaesthesiol Clin N Am 13(2):411-37. doi: 10.1016/S0889-8537(21)00528-9
33 Royal College of Anaesthetists. (2009) Major complications of airway management in the United Kingdom - 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Available at
34 https://www.rcoa.ac.uk/sites/default/files/documents/2023-02/NAP4%20Full%20Report.pdf accessed 01 Aug 2025.
35 Aydin ZIA, Avci II, Avci IE. (2025). Factors associated with placement failure of second-
36 generation laryngeal mask airway: a retrospective clinical study. Acta Medica Nicomedia 8(1):1-10. doi: 10.53446/actamednicomedia.1486989
37 Alexander R, Hodgson P, Lomax D, Mullen C. (1993) A comparison of the laryngeal mask airway and Guedel airway, bag and facemask for manual ventilation following formal training. Anaesthesia 48(3):231-4. doi: 10.1011/j.1365-2044.1993.tb06909.x
38 Lasik J, Klosiewicz T, Puslecki M. (2025) Quality of bag-valve-mask ventilation in adults: a comparison of paramedic and nurse performance. Disaster Emerg Med J 10(2):85-93. doi: 10.5603/demj.104569
39 Perlas A, Brull R, Chan VW. (2008) Ultrasound guidance improves the success of peripheral nerve blocks: a meta-analysis. Reg Anaesth Pain Med 33(3):213–218.
40 Barrington MJ, Kluger R. (2013) Ultrasound guidance reduces the risk of local anaesthetic systemic toxicity following peripheral nerve blockade. Reg Anaesth Pain Med 38(4):289–297
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