This explored Design for Resilient Performance (DfRP) via their framework. Not a summary – just a few extracts, but maybe I’ll summarise it in the future. Some extracts: · “Resilient performance (RP) is a socio-technical system’s ability to adjust its functioning prior to, during, or following changes and disturbances, thereby sustaining operations under both expected and… Continue reading Designing work systems for resilient performance: insights from resilience engineering
Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
This systematic review evaluated evidence for what support staff want vs what they receive, and whether the support is effective. 99 studies were included. Some extracts: · PSI (patient safety incident) lead to emotional shame, guilt, anger, shock, depression, fear, flashbacks, helplessness, fatigue, withdrawal and more · The three most desired support types staff want before and… Continue reading Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
Resilience terminology and a visualisation of resilience/robustness in practice
This may interest people. It covers concepts of resilient performance within seaports. It’s a bit random (seaports), but otherwise gives a handy overview of resilience terms and applications. The first two images are just basic definitions. Extracts: · Image 3 represents resilience elements during disruptions – from pre-disruption, to the disruption, then post-disruption. · During pre-disruption, the… Continue reading Resilience terminology and a visualisation of resilience/robustness in practice
The bad apple theory won’t work: response to ‘Challenging the systems approach: why adverse event rates are not improving’ by Dr Levitt
Another rebuttal article as a follow-up from the prior post on systems thinking in medicine, again from Dekker & Leveson. I’ve skipped Levitt’s letters which prompted these letters to the editor. Extracts: · “One can understand the seduction of sanctioning non-compliant doctors2 or getting rid of the deficient practitioners—the system’s bad apple” · They refer to research… Continue reading The bad apple theory won’t work: response to ‘Challenging the systems approach: why adverse event rates are not improving’ by Dr Levitt
Cultural elements of major accidents according to Andrew Hopkins
Not much to say, just an extract from Andrew Hopkins’ 2006 paper ‘Studying organisational cultures and their effects on safety’. I’ll be posting the summary in the coming weeks. Here he describes his analysis of the 1999 Glenbrook rail crash: · He identified four main cultural themes preceding the disaster · First “the railways were obsessively rule… Continue reading Cultural elements of major accidents according to Andrew Hopkins
Unveiling Untapped Potential: Leveraging Accident Narratives for Enhanced Construction Safety Management
This study explored the value and insights derived from investigation reports, comparing tabulated data vs extracted narratives. It was interested in what sorts of trends and insights about risk factors could be derived from either data stream. Their method to extract the info was tested against 400 OSHA reports. For context: · Tabular data is… Continue reading Unveiling Untapped Potential: Leveraging Accident Narratives for Enhanced Construction Safety Management
Mini-Compendium: Psychological Safety
Given the prominence of Psychological Safety (PS), it’s worth sharing some research. It’s likely among the most studied modern concepts in organisational theory – so I can barely scratch the surface. Focus first is articles I’ve summarised, and then on any other full-text items I can find. In my haste, I’ve probably included some psychological… Continue reading Mini-Compendium: Psychological Safety
A perspective on applying Just Culture and Safety-II principles to improve learning from sentinel events in healthcare
This discussion paper from de Vos, Dekker and others discusses applying Just Culture and Safety-II to improving from healthcare sentinel events. I think it’s based on de Vos’s PhD. They start showing some evidence that among hospitals convinced that they have a “blame-free” culture also “reported that culpability was of primary concern in their investigations… Continue reading A perspective on applying Just Culture and Safety-II principles to improve learning from sentinel events in healthcare
The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
This was a really brief discussion paper from Dekker and Leveson, covering systems thinking in medicine. Three parts – see comments. Nothing new for most, but they cover: · “The ‘systems approach’ to patient safety has recently led to questions about its ethics and practical utility” · E.g. A recent paper from a retired neurosurgeon questioned systems… Continue reading The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
List of research compendiums on my site
Did you check out my recent compendium on power in organisations and safety? >72 studies (mostly full-text) to read. Quoting Dekker & Nyce 2014: “this considers power as a process that pervades all aspects of organizational life. In other words, there is power in safety—everywhere in safety”. This adds to 11 other compendiums, covering research… Continue reading List of research compendiums on my site
SafetyInsights.org 