Here is an extract from James Reason’s “Organizational Accidents Revisited” book (p103). He discusses various “alternative views” around organisational accidents, including Barry Turner’s disaster concept, Chick Perrow and Normal Accident Theory and also the contributions from David Woods et al. around cognitive systems. Here he’s talking about the work from Woods et al. regarding the… Continue reading James Reason and his bitter refusal around “error”

This study explored the human cost of Resilient Performance (RP), in the form of burnout, among healthcare professionals. That is, calls to enhance the potential for resilience (resilient potentials) may have an underappreciated toll on people, as they adapt to system deficiencies which further become masked and normalised. Providing background, it’s noted: This paper draws… Continue reading Burnout and network centrality as proxies for assessing the human cost of resilient performance

I don’t post much on Zero Harm (mainly because there’s not a lot of quality published evidence surrounding it), but this paper from Fidelis Emuze and Fred Sherratt may be of interest. They explore the topic of “making zero harm work for the construction industry”. They draw on Cynefin to describe construction work and then… Continue reading Making zero harm work for the construction industry

This paper unpacks the Air France 447 crash from 2009 and provides an alternate view of the accident’s genesis. While the official report “place scrutiny on the aircrew’s subsequent lack of awareness of what was going on and of what procedure was required, and their failure to control the aircraft”, this view is inappropriate and… Continue reading Pilot error versus sociotechnical systems failure: a distributed situation awareness analysis of Air France 447

What is the relationship between sleep problems and work-related injury? I’ve posted a few studies in the past (links below) exploring relative risks or odds ratios of work-related accidents due to different work schedules. An upcoming meta-analysis I’m posting (although from 2014, so caveat on the age of data) explored this question in relation to… Continue reading Sleep problems and work injuries

An interesting study exploring workplace adaptations at all stages of the vein to vein blood transfusion. Although transfusion is considered one of the safer areas of healthcare, some deaths are still associated with transfusions each year. An earlier study from these authors found a tendency for individual staff members to be blamed for incidents, rather… Continue reading Resilience in the blood transfusion process: Everyday and long-term adaptations to ‘normal’ work

This study designed and tested two new survey instruments aligned with High Reliability Organisation (HRO) theory: 1) preoccupation with failure and 2) adherence to shared baselines. HRO concepts (which also include the similar concept of highly reliable organising rather than a high reliability organisation) typically involves five principles or factors: 1) sensitivity to operations, 2)… Continue reading Preoccupation with failure and adherence to shared baselines: Measuring high-reliability organizational culture

This 2010 study used data from 2004-2008 to evaluate the effectiveness of safety interventions in improving safety performance. Data was obtained from a selection of participating Dutch organisations, as part of a program run by the Dutch Ministry of Social Affairs and Employment. 29 companies were included and a total of 298 safety interventions. Organisations… Continue reading Evaluating safety management and culture interventions to improve safety: Effective intervention strategies

One of several great videos from Johan Bergström on YouTube. This one discusses two “schools” of thought on error: (1) the cognitive psychological school and (2) the joint cognitive school It’s an interesting 4 minutes. Link: https://youtu.be/rHeukoWWtQ8 Shout me a coffee

Just finished summarising a study that explored the links between sleep hygiene and shift work disorder within a sample of shift workers. (FYI Shift work disorder is a chronic disruption to circadian rhythms due to working irregular shift schedules.) In short, the findings supported a body of evidence on the value that sleep hygiene can… Continue reading Shift work disorder and sleep hygiene index