This may interest my network. Nektarios Karanikas and Haroun Zerguine argue that new safety paradigms, HOP, S-II, SD etc.: • do not focus exclusively on safety. • do not consider dynamic and diverse organisational contexts. • can contribute to safety but are not inclusive and sufficient to ensure it. • deserve consideration provided their limitations are acknowledged. Link:… Continue reading Are the new view safety approaches sufficient to ensure safety? So asks a critical commentary

How effective are warnings? So explores a meta-analysis of 30 studies. Warnings include hazard labels, signs, safety data sheets, medication and more. A few key findings: ·      Recall of a warning’s content was significantly facilitated by its level of sensory conspicuity (e.g. how visible, like with red or yellow boundaries) ·      Presence of descriptive words and pictures,… Continue reading How effective are safety warnings? A meta-analysis of 30 studies

This paper explored the application of micro-experiments with a rule management framework in order to close gaps between work-as-imagined (WAI) and work-as-done (WAD). The approach was applied to several examples where a gap was evident in an operational squadron within the Royal Netherlands Air Force. Note: There’s way too much to cover in this paper… Continue reading Reducing gaps between paper and practice requires more than a technical alignment

Does the hierarchical nature of organisations, such as in medicine, inhibit speaking up and voice behaviour from those lower in the hierarchy? A systematic review in healthcare suggests yes. A 2020 study evaluated 19 papers for the links between hierarchy and voice behaviour in response to human performance variability (e.g. medical errors and the like).… Continue reading Hierarchy and medical error: Speaking up when witnessing an error

This paper evaluated whether investigations findings and corrective actions were influenced over time by a national focus on Prevention Through Design (PTD) and the Hierarchy of Control (HoC). That is, they’re comparing investigations prior to and following a particular time point (2007) for differences in what causes are attributed (e.g. active or latent failure types)… Continue reading SH&E Problem Solving: Are Higher-Order Controls Ignored?

An upcoming summary analysed 75 investigation reports from the U.S. Chemical Safety and Hazard Investigation Board (CSB), exploring the attributed causal/contributory factors and the types of corrective actions implemented. In this study, they grouped the accident factors into errors…for some reason. Of course, these types of categories depend on worldview, definitions etc, and can be… Continue reading Process accidents and the use of weaker corrective actions and improvements

A new study from Leonie Boskeljon-Horst, Robert J. de Boer and Sid Dekker exploring micro-experiments and a rule management framework to close gaps between work-as-imagined (WAI) and work-as-done (WAD). This was based in an operational squadron of the Royal Netherlands Air Force. Summary to be posted soon. In this study they applied micro-experiments and a… Continue reading Micro-experiments and monitoring and adapting rules to close the gap between work-as-imagined and work-as-done

This reviewed the published evidence for the interventions and measurements used in HRO implementations (and lesser degree, RE). Of 1400 studies 34 were included. Given overlaps with resilient organisation and RE concepts, some of this work was also included. A key focus was on the question “how do you know if you’re an HRO and… Continue reading Interventions and measurements of highly reliable/resilient organization implementations: A literature review

This brief open access paper may interest you – the authors detail systems principles that can be applied by healthcare teams to “analyse, learn and improve from unintended outcomes, reports of excellent care and routine everyday work ‘hassles’”. I don’t think it’s intended as a replacement for other systems frameworks, nor a systematic approach, but… Continue reading Development and application of ‘systems thinking’ principles for quality improvement

This systematic review evaluated the research between leadership walks on clinical outcomes. 12 studies met inclusion criteria. Providing background: ·       Different type of leadership walks exist, including management-by-walking-around (MBWA). Gemba Walks, and Patient Safety Leadership Walkarounds (PSLWs) ·       A prior lit review of PSLWs found that, despite the limitations of studies, LWs were generally effective… Continue reading Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review