SafetyInsights.org

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 Consider the age of the paper before commenting on the rather outdated language, which I’ve mostly retained in my summary.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

This study explored the relationship between lack of sleep on the development of leader-follower relationships from initial commencement to over time. 40 leads and 120 followers were included in the study. Providing background they note: Results Key findings included: It’s argued that these findings challenge and extend LMX (leader-member exchange theory), which have largely focused… Continue reading Lack of sleep and the development of leader-follower relationships over time

One of the classics from Amy Edmondson (2004), exploring the relationships between group and organisational factors on drug administration errors. Note: there’s lots to say and debate on the term “human error” (check out my site for several papers critical of the term), but for my own convenience I’m sticking with the terminology in the… Continue reading Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error

This looked at the relationships between operational practices and safety practices and outcomes – and the impact of Joint Management System (JMS) practices rather than safety or operations (OPS) managed separately. 10 facilities from 9 companies were included. Based on analysis, facilities were divided into two dominant “cultures” based on their characteristics: 1) a supportive… Continue reading Understanding safety in the context of business operations: An exploratory study using case studies

A classic from David Woods & the late, great Richard Cook. Here they critique the label of “human error”, as if “it were an explanation for what happened”; rather being a label that organisations can readily get stuck on. They provide nine generalised steps to help organisations move on from these labels and enhance learning… Continue reading Moving on from labels of human error