SafetyInsights.org

A new study from Leonie Boskeljon-Horst, Robert J. de Boer and Sid Dekker exploring micro-experiments and a rule management framework to close gaps between work-as-imagined (WAI) and work-as-done (WAD). This was based in an operational squadron of the Royal Netherlands Air Force. Summary to be posted soon. In this study they applied micro-experiments and a… Continue reading Micro-experiments and monitoring and adapting rules to close the gap between work-as-imagined and work-as-done

This reviewed the published evidence for the interventions and measurements used in HRO implementations (and lesser degree, RE). Of 1400 studies 34 were included. Given overlaps with resilient organisation and RE concepts, some of this work was also included. A key focus was on the question “how do you know if you’re an HRO and… Continue reading Interventions and measurements of highly reliable/resilient organization implementations: A literature review

This brief open access paper may interest you – the authors detail systems principles that can be applied by healthcare teams to “analyse, learn and improve from unintended outcomes, reports of excellent care and routine everyday work ‘hassles’”. I don’t think it’s intended as a replacement for other systems frameworks, nor a systematic approach, but… Continue reading Development and application of ‘systems thinking’ principles for quality improvement

This systematic review evaluated the research between leadership walks on clinical outcomes. 12 studies met inclusion criteria. Providing background: ·       Different type of leadership walks exist, including management-by-walking-around (MBWA). Gemba Walks, and Patient Safety Leadership Walkarounds (PSLWs) ·       A prior lit review of PSLWs found that, despite the limitations of studies, LWs were generally effective… Continue reading Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review

An interesting 2017 thesis from Les Meintjes analysing fatalities in Queensland Metalliferous Mines from 1879 to 2016, with a focus on the latter period’s fatalities. This was meant to be a mini-post but grew into an article. [P.S. Yes I know about the Brady review. Check my site as I’ve covered it] Key findings- Safety… Continue reading Critical Analysis of the Queensland Metalliferous Mines Fatal Accident Record

This study explored the interaction of safety management system elements and safety climate on safety in the construction sector. 349 Singapore construction companies were included in the sample. Providing background: Their analytical model is shown below: Results Overall, they found that “the interaction of safety incentives, subcontractors’ involvement, and safety accountability with SMS have positive… Continue reading The role of the safety climate in the successful implementation of safety management systems

Have national focuses on the hierarchy of control and prevention through design influenced investigation findings over time? A 2014 paper from Michael Behm and Demetria Powell explored this question. Comparing 249 investigation reports prior to 2006 and from 2008 to 2014: 1)     Incident causes categorised as either latent or active failures have not statistically changed over… Continue reading Investigation recommendations and the hierarchy of control

Do Leadership Walkarounds (LWs) positively impact operational, cultural and clinical outcomes? Another systematic review (in healthcare, again) suggests ‘Yes’. 12 healthcare studies met inclusion criteria. First, they noted based on prior evidence: ·        A prior lit review found that LWs were generally effective in informing leaders on safety issues that impacted front-line staff and patients ·        LWs… Continue reading Leadership walkarounds and performance improvement

This explored via interviews with 33 employees their experiences with using an incident reporting system (RUO; reports of unwanted occurrences) and the barriers to reporting incidents. Previous research was first covered in the paper. Issues of trust and blame inhibit reporting, as is also related to solidarity between colleagues. Other factors include unclear reporting guidelines,… Continue reading A study of experience feedback from reported unwanted occurrences in a construction company

Not much to add here – images 1 and 2 are excerpts from one of Dekker’s papers that I found interesting; and an image on different figurative ‘ages’ of safety evolution from Pillay et al. Note: You probably shouldn’t take image 1 too literally, but it serves more as a general indication of how science… Continue reading The evolution of safety science