This study explored whether outcome bias might explain why healthcare investigations focus on individual culpability over addressing latent conditions in the system. 212 participants were allocated to one of three scenarios followed by the findings of an investigation (see scenario overviews below). For background: · Prior work has identified that the “overwhelming majority of recommendations… Continue reading Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
Tag: blame
Humans are fallible and we should design out harm: 1913 rail safety article
“What a time to be alive!” – People in 1913, probably. This interesting article from 1913 about rail safety comes to some interesting proposals: human fallibility is a normal and expected thing, that we should seek design and systems solutions where possible, and companies always prioritise profit over ‘safety’ trade-offs: · “In the past, when an accident… Continue reading Humans are fallible and we should design out harm: 1913 rail safety article
Allocation of Blame After a Safety Incident
This single page conference paper discussed an experiment on how blame is allocated following incidents. The scenario was a “realistic, but fictitious” incident involving a worker (both experienced or not experienced, depending on the scenario), whom is killed when touching an energised bus bar while feeding electrical wire into a pedestal. They systematically manipulated the… Continue reading Allocation of Blame After a Safety Incident
Compendium: Blame, Just Culture & language
Here’s another compendium of articles exploring blame and language in the construction of post-hoc causality explanations, or how blame effects learning and investigations. The other part covers some articles around Just Culture and restorative culture. Note: I’ve mostly focused on articles that I’ve either already summarised or that I could find a full text link… Continue reading Compendium: Blame, Just Culture & language
From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
This 2018 paper explored the effects of a re-designed Just Culture (JC) process in an international energy company. It’s a solid read and worth your time – I’ve had to skip heaps. Providing background: · This organisation started using the James Reason JC framework in 201, but collective experience in the organisation “indicated that the… Continue reading From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
SafetyInsights.org 