Another graphic from James Reason. In his vulnerable system syndrome paper (link below) he talks about types of “pathologies” present in many organisation; which predispose them to adverse events. Three interacting and self-perpetuating elements are involved: blaming front-line individuals, denying the existence of systemic issues and a blinkered pursuit productive and financial indicators. Three core… Continue reading The blame cycle

A really interesting study which explored the relationship between cultural factors and organisational failures. 58 studies were included in the review. Way too much to cover in this paper – I recommend you grab the full paper if it interests you. Also, for those critical of “safety culture”, this paper more explores how research has… Continue reading Causal and Corrective Organisational Culture – A Systematic Review of Case Studies of Institutional Failure

Another earlier paper (2004) paper from James Reason, talking about the progression of active and latent conditions related to a fatal medication event. From this he discusses enhancing “error wisdom” to buttress organisational safety approaches. Note – I think some of the terminology and ideas are a bit dated. However, if you apply a modern… Continue reading Beyond the organisational accident: the need for ‘‘error wisdom’’ on the frontline

The follow up paper on cognitive debiasing. This paper covers a scheme of cognitive change relating to debiasing, the constraints to change, and then a range of techniques directed at cognitive and affective debiasing. [** Note that there’s more systematic and recent reviews on debiasing techniques. I’ll cover some of these in the near future.]… Continue reading Cognitive debiasing 2: impediments to and strategies for change

One of two papers exploring the nature of cognitive biases and heuristics in medical decisions. These papers have some interesting points that are relevant outside of medicine. They’re also open access, so you can read the full papers yourself. I’ll be posting a few studies in the coming period on debiasing, decision-making and similar themes.… Continue reading Cognitive debiasing 1: origins of bias and theory of debiasing

This study explored whether joint management system (JMS) practices (integrated OHS and Operations [Ops.] practices) result in better performance compared to alternative practices or individually.  198 manufacturing organisations were studied. Four groups were identified: 1) JMS groups excelling in both Ops. performance and OHS performance; 2) groups that scored high in Ops. but low in… Continue reading Managing Safety and Operations: The Effect of Joint Management System Practices on Safety and Operational Outcomes

This 2001 paper from Jim Reason and crew discusses Vulnerable System Syndrome (VSS). VSS describes a “cluster of organisational pathologies … [that] render some systems more liable to adverse events” (p21). VSS includes three interacting and self-perpetuating elements: 1) blaming front line individuals, 2) denying the existence of systemic error provoking weaknesses and 3) the… Continue reading Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management

This study evaluated the use of a Safety-II/Resilience Engineering (RE) inspired safety huddle tool, called the Green Line. The setting was a neonatal care unit in Sweden. The Green Line draws on prompts of both failure, success and tries to encourage people to engage and learn about the entire spectrum of work. It also frames… Continue reading Experience of learning from everyday work in daily safety huddles—a multi-method study

An ethnographic study from four construction projects, regarding the social context on work practices & safety between principal contractors (PC) and subcontractors (SC). Way too much to cover, so I’ll pick a few points. First, regarding rules, PC forepersons were found to be flexible with compliance – trading off strict enforcement with the need to… Continue reading Safety at the Front Line: Social Negotiation of Work and Safety at the Principal Contractor–Subcontractor Interface

This paper discussed two different accidents and contrasted their investigative approaches using the naturalistic decision-making (NDM) framework. This is a really long summary given the richness of the paper. Hang with it to the end as I think the author has some interesting insights to share. For background – even in dynamic and ill-structured situations,… Continue reading Decision Errors and Accidents – Applying Naturalistic Decision Making to Accident Investigations