This study mapped similarities between the concepts of work engagement and Safety-II (S-II) – and in particular, the antecedents for each. I’ve skipped large portions of this paper and particularly the research behind the engagement constructs (which I’ve mainly skipped to the S-II comparison discussion in each section), so recommend you check out the full… Continue reading Safety through engaged workers: The link between Safety-II and work engagement

An interesting study exploring how simulator training of maritime deck officers can improve the management of Performance Variability (PV) & safety in critical operations at sea. Learning & PV was framed through the lens of Safety-I (SI) / Safety-II (S-II) & Resilience Engineering (RE). Too much to unpack so I’ll cover just a few points. … Continue reading Balancing Safety I and Safety II: Learning to manage performance variability at sea using simulator-based training

Another classic from Richard Cook, where he covers 18 principles on how complex systems fail. The paper is brief, freely accessible and an easy read. I’ve extracted the 18 principles with a small text description in the below images. Some random highlights for me are: Source: Cook, R. I. (1998). How complex systems fail. Cognitive… Continue reading How complex systems fail (a classic from Richard Cook)

A discussion paper from David Woods and Richard Cook where they explore some general research findings about how complex systems fail and how people contribute to safety. They argue that some common beliefs and fallacies on why high risk systems fail, and normally succeed, can hold back progress. There’s way too much to unpack from… Continue reading Nine Steps to Move Forward from Error

This study, including Sidney Dekker as co-author, evaluates the impact of a new response framework following critical incidents – called the Gold Coast Clinical Incident Response Framework (GC-CIRF). GC-CIRF utilises a Restorative Just Culture (RJC) framework and Safety-II principles. A number of initiatives were involved in the framework, including tools for carers to use post… Continue reading Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

This studied self-reported workarounds in healthcare (4k nurses & 63 US hospitals) and matched it to pressure injury incidence data (>21k patients). Workarounds are explored in the context of the frequency of Operational Failures (OF), defined as “breakdowns in the supply of materials, equipment, and internal services needed to complete tasks”. Thus, in this study… Continue reading When do workarounds help or hurt patient outcomes? The moderating role of operational failures

Safety failures, so it goes, are caused by unreliable or erratic performance of individuals working at the sharp end. This is a first story. First stories focus on agency of individuals and how they undermine systems that are inherently safe. First stories are noted to appear as attractive explanations for failure, but ultimately lead to… Continue reading The allure of first stories, the tragedy of second stories and the levers for learning

Quite an older (1991) book chapter from James Reason, where he explores different facets of organisational accidents and limitations/caveats of incident reporting systems. Consider the age of the paper before commenting on the rather outdated language, which I’ve mostly retained in my summary. He argues that while reporting systems can provide important information, as sources… Continue reading Too little and too late: A commentary on accident and incident reporting systems

This explored the role of continuous quality improvement (CQI; involving management style & personal influence) and psychological safety (PS) as predictors of work-arounds in health care; 83 employees were surveyed. Work-arounds were defined as “work procedures that are undertaken to address a block in work flow”. The authors note that work-arounds “have become so common… Continue reading The role of continuous quality improvement and psychological safety in predicting work-arounds

Amy Edmondson in the Fearless Organization talks about the asymmetry of voice and silence – see below. People “err so far on the side of caution that they routinely hold back great ideas – not just bad news” (p34). Indeed, these voice-silence calculations can make real differences during critical moments, with silence tending to be… Continue reading The asymmetry of voice/silence or the sounds of silence