SafetyInsights.org

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

A really interesting 2000 paper from James Reason exploring some apparent paradoxes in safety. A paradox is “a statement contrary to received opinion; seemingly absurd though perhaps well-founded” (p3). The pursuit of safety “abounds with paradox”, and in modern complex sociotechnical systems, things aren’t always what they seem. That is, some beliefs and traditions in… Continue reading Safety paradoxes and safety culture

This studied the impact of OHSAS 18001 certification (18001) on safety performance across 5,147 Spanish firms. First, they covered existing research – finding limited work. Findings across studies were inconsistent, with some finding improvements in safety performance and in others no improvement. Some existing work suggests that safety management system (SMS) & certified system adoption… Continue reading OHSAS 18001 certification and work accidents: Shedding light on the connection

Another from the Reason files (I have a few more of these). The image below explores the maturity cycle organisations go through regarding the role of people. First, problematically, people are seen as hazards. And according to management logics, hazards should be controlled and the variability damped. This focus separates people and behaviour from the… Continue reading Of heroes, villains, error traps and accidents

This systematically reviewed the evidence on incident reporting systems (IRS) in healthcare. Of 43 studies, 8 compared IRS with other healthcare methods and 35 explored the effectiveness of IRS on settings, structures and outcomes. It’s a 41-page review, so I’ll only provide some key findings and not the discussion around the findings. Results Key findings… Continue reading How effective are incident‐reporting systems for improving patient safety? A systematic literature review