This study explored the role of a culture of openness on mortality rates among 137 English hospital systems between 2012-14. Thanks to sidneydekker.com for flagging this paper during the recent Global Safety conference. Providing background: ·       It’s said that while many agree about the importance of openness, it has “proved difficult to define and operationalize… Continue reading A culture of openness is associated with lower mortality rates among 137 English National Health Service Acute Trusts

This full open access paper is an interesting read. It explored the role of metaphors in safety. Specifically, they discussed: 1)     how metaphors influence the comprehension of organizational accidents 2)     how graphical representation of metaphors shape observer comprehension of accidents They note that current sociotechnical systems are characterised by complex interactions and pose a challenge in their… Continue reading How Metaphors of Organizational Accidents and Their Graphical Representations Can Guide (or Bias) the Understanding and Analysis of Risks

It’s been a while since I shared this, but here’s a brief conference paper I published in `18, exploring fantasy planning and false assurance. (It’s a heavily trimmed version of a much larger paper I hope to one day publish in full.) We explore several angles on the sources and problems of fantasy planning. First… Continue reading My 2018 conference paper: Fantasy planning: the gap between systems of safety and safety of systems

This study evaluated the impact of an integrated Crew Resource Management (CRM) training program on failure to rescue (FTR) mortality. Two hospitals, one control and one intervention, were compared after 3 years. The CRM program in the intervention hospital consisted of a 4-hr comprehensive CRM program and included all surgical services employees (>1,600 people), and… Continue reading Failure to rescue and 30-day in-hospital mortality in hospitals with and without crew-resource-management safety training

This full open access paper may interest you – it evaluated the literature to canvass how learning is conceptualized in the Resilience Engineering (RE) research. They found that theoretical conceptualisations of organizational learning from resilient performance are under-developed, and fragmented. RE researchers have thus far conceptualised the process of learning as “understanding the system, sharing… Continue reading Conceptualising learning from resilient performance: A scoping literature review

What’s the association between a culture of openness among staff and subsequent patient mortality? An interesting study to be posted soon explored this relationship. Thanks to sidneydekker.com for flagging this paper during the recent Global Safety Innovation Summit 2024. Openness represents an “environment in which communication among patients, staff members, and managers is open and… Continue reading Higher staff openness scores linked to lower patient mortality in English hospitals

This studied the impact of ethical leadership on safety & task performance under the effects of two safety-critical factors: 1) perceived accident likelihood, 2) perceived hazard exposure. Ethical leadership is defined as “the demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through two-way communication,… Continue reading Examining the impact of ethical leadership on safety and task performance: a safety-critical context

This open access paper explored the relationships between power distance and leader inclusiveness on psychological safety, and resident willingness to report adverse events. Sample was 106 residents in a US teaching hospital. Key findings: ·      Perceived power distance and leader inclusiveness both significantly predicted psychological safety ·      This in turn significantly predicted intention to report adverse events… Continue reading The effects of power, leadership and psychological safety on resident event reporting

This chapter explores an organisational “imagined disease”, termed by the author as “auditism” [** I love this term]. I’ll be using a lot of direct quotes. I haven’t done a good job of this, so recommend you check out the chapter. It’s noted that we’re surrounded by auditism and have been convinced that what we… Continue reading Auditism: Symptoms, Safety Consequences, Causes, and Cure

This study explored how psychological safety (PS) affects near-miss reporting and learning in radiation oncology. They note that near misses contain contrasting cues highlighting both resilience and vulnerability. Based on prior work from Dillon, Tinsley et al., they note that a near miss may have cues of resilience (“we avoided failure”) and vulnerability (“we nearly… Continue reading Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology