Not much to say here – this paper exploring the potential role of S-II and adaptive thinking in the management of future gas systems may be of interest. It’s open access, so I’m not summarising it. Some extracts attached as images. (P.S.: As with many concepts, try not to take the ideas of S-II too… Continue reading Incorporating Safety-II in future gas systems

This ethnographic study explored the ritualistic and ceremonial functions of a Surgical Safety Checklist (SSC) in an urban teaching hospital. It’s a pretty interesting read that I can’t do justice. Providing background: Results Observing the use of the SSC in practice revealed: ·       The use of the SSC was found to function as a ceremonial… Continue reading The ritualisation of the surgical safety checklist and its decoupling from patient safety goals

This study explored the relationships between leader humility, psychological safety and employee engagement. Data came from 140 workers via an online survey platform. Providing background: ·         Since the 1930s, >65 classification systems have been developed to describe the dimensions of leader behaviour ·         Two outcomes have commonly being used to frame effective leadership: followers’ psychological… Continue reading Humble Leadership: Implications for Psychological Safety and Follower Engagement

Pretty chuffed that our brand spanking new study on major accident audit failures is already the fifth most read paper in the Journal of Process Safety Progress (* at least according to their stats, I don’t know how rapidly these lists change, nor their entire scope). No doubt this has largely been driven by kind… Continue reading Major audit failure paper ranked in top 5 most ‘read’ list of journal of Process Safety Progress

What are the links between risk avoidance and locus of control in workers experiencing near misses? A study to be posted soon explored these links from >1.3k US miners. First, risk tolerance/avoidance/propensity is an individual’s tendency to take or avoid risks, and risk avoidance is an “emergent trait that can change”. Locus of control is… Continue reading Links between locus of control, risk avoidance and near misses in mining

Can safety checklists become ritualistic performances disconnected from their core goal, thereby increasing risk? A new study to be posted soon explored this question. Cliff’s notes: Possibly yes. Surgical Safety Checklist (SSC) practices in a Canadian hospital Operating Room were observed via an ethnographic approach, combined with interviews, surveys and document analysis. Overall they found:… Continue reading Surgical Checklists behaving badly…new study suggests they can result in ritualistic practices decoupled from their core goals

Our recent study of 44 major or fatal accident reports in the process, chemical, pipeline, mining, oil & gas industries explored how audits failed prior to the accident (according to the investigation). I’ll cover some findings over a couple of posts. Note that hindsight bias, counterfactual reasoning and second order/double hermeneutics are a recurring and… Continue reading Major accident audit failures: a failure to understand and a failure to sufficiently act

A really interesting study that quantified the energy magnitude and intensities of various fatal and non-fatal accidents; energy estimates which then can be used to predict the severity of incidents. >500 injury reports were analysed. There’s way too much conceptual background and discussion in this paper for me to cover (e.g. entire sections discussing energy… Continue reading Energy-based safety risk assessment: does magnitude and intensity of energy predict injury severity?

This coroner’s report detailed the sad case of a medical misdiagnosis, resulting in a death. Here, a young adult died due to undiagnosed bacterial meningitis, diagnosed primarily as middle ear infection (the ear infection led to meningitis). Interestingly, the coroner framed the core findings using the Swiss Cheese metaphor (** despite its limitations in complex… Continue reading Coroners report on fatal medical misdiagnosis: availability bias, anchoring, fatigue and “voluminous guidelines” that sit unread

This study explored the beliefs and organisational contexts of  nursing aide (caregivers henceforth) assaults and their subsequent reporting of these events. Although this data is a pretty specific cohort and setting (rural nursing homes), the social and systems lenses that the authors take, and the silence resulting from blame attributions have broader applications. Providing context:… Continue reading Taking the Hit: Focusing on Caregiver “Error” Masks Organizational-Level Risk Factors for Nursing Aide Assault