I’m sure I’ve posted this before (and likely many others have), but I love this idea from Karl Weick (and James Reason’s paraphrase of it) as reliability and safety as “dynamic non-events”. For “nothing” to happen (stable outputs, lack of unexpected or undesirable performance, events etc.), continuous and skilful inputs from adaptable agents is necessary.… Continue reading Safety as a dynamic non-event

This explored the extent and nature of blame in family practice safety incident reports. 2148 incident reports from a database of 14 million reports was analysed. Blame was defined as “evidence in the free-text of a judgement about a deficiency or fault by a person or people” (p457). Problems exist with current approaches to incident… Continue reading Nature of Blame in Patient Safety Incident Reports: Mixed methods analysis of a national database

This was an interesting little study that evaluated the performance of a routine incident reporting system in identifying, and more importantly missing, patient safety incidents. Data was compared between patient case notes and via analysis of the incident report data for the same patients; 1006 hospital admissions were evaluated. Results Of the 1006 admissions, 324… Continue reading Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review

This explored the role employee electronic monitoring (EM) plays in undermining ethical leadership by eroding trust. Data was via survey from a diverse field sample of supervisors and their employees. Providing background on ethical leadership and employees, it’s said: Relating to EL and EM: Results Core findings included: They also found that monitoring had no… Continue reading The (electronic) walls between us: How employee monitoring undermines ethical leadership

This study explored how workplace monitoring of employees (e.g. via surveillance systems in email, screens, vehicle IVMS, cameras etc.) impacts employee behaviour and how, when and why it may result in greater unethical (“deviant”) behaviour. Two separate studies were ran. Nicely, the paper begins with a quote from one worker reflecting on his experience with… Continue reading Stripped of Agency: The Paradoxical Effect of Employee Monitoring on Deviance

This studied the effects of training supervisors in leadership (LX) theory around transformational (TFL) and active transactional behaviours (TSL) on leadership behaviour, safety climate, employee safety behaviours after a 8-week period. TFL emphasises inspiring and motivating leader behaviours; which in turn, encourages employees to engage in higher levels of safety participation and noted to build… Continue reading Reducing workplace accidents through the use of leadership interventions: A quasi-experimental field study

I think it’s safe to say there’s differing opinions on the relationships between hazards & minor/major precursors & events. In one stream, a delineation is drawn for process vs personal indicators & hazards; nicely articulated by Andrew Hopkins discussing the BP Texas City disaster – where BP was largely relying on injury metrics over process… Continue reading Relationship between minor and major accidents

This brief discussion paper quickly discussed a few methods used in healthcare for managing variation and quality of care. They included: Incident reporting systems Investigations Checklists Providing background, it’s said that: Some industries have been particularly successful at managing variability at a systemic and sophisticated level – aviation for instance But noting this, variability is… Continue reading Are we using the right tools to manage variation, errors and omissions?

Abstract Objectives Regarding the causes of sleep-related accidents, this study assesses whether individuals can anticipate sleep onset accurately and how individuals acknowledge and use physiological and cognitive cues to make judgments related to sleep onset. Methods A group of 41 partially sleep-deprived subjects predicted the likelihood of sleep in 30 consecutive two-minute intervals and noted… Continue reading Awareness of sleepiness and ability to predict sleep onset: Can drivers avoid falling asleep at the wheel?