Extracts from a paper that studied medication safety in primary care from both a Safety-I and Safety-II lens – using “medication management in the wild” as their data. · 2 decades after the ‘To Err is Human’ report has “given way to hard bitten realism that there has been little measurable improvement in the overall rates… Continue reading Safety-I Versus Safety-II: A Mixed-Methods Study Revealing the Imbalance of Approaches in Primary Care Medication Safety
Tag: hop
Safe As 38: 4Ds – Dumb, Dangerous, Different, Difficult – for learning (quickisode)
This quickisode unpacks the 4D method for learning: Dumb, Dangerous, Different, Difficult. The source is Sutton et al. 2023. 4Ds for HOP and Learning Teams: A practical how-to guide to facilitate learning from everyday work, critical and dynamic risks with the 4Ds. Spotify: https://open.spotify.com/episode/5kVSsQBISQK3vMREbUGExv?si=LOvB1DE1SfCE-8E7uYSK_Q Apple: https://podcasts.apple.com/us/podcast/e38-4ds-dumb-dangerous-different-difficult-for-learning/id1819811788?i=1000727889641 Make sure to subscribe to Safe As on Spotify/Apple,… Continue reading Safe As 38: 4Ds – Dumb, Dangerous, Different, Difficult – for learning (quickisode)
Learning from normal work in complex sociotechnical system—Case in midstream operation
This article discussed learning from normal work, via semi-structured episodic interviews. It’s open access, so not a summary. Extracts: · Briefly discussing historical safety progression, “safety progress was achieved by expanding existing rules to cover more potential failures, and safety failures resulted from gaps in rules or their lack of application” · “However, no procedure, no matter… Continue reading Learning from normal work in complex sociotechnical system—Case in midstream operation
Safe As 30: A better way to think about procedures – resources for action
Do you see procedures as concrete actions that specify the one correct way of working, or more as resources to shape work and sensitise people to risk? Let’s unpack the model 1 / model 2 perspective of rules and see which resonates best with workers. Today’s paper is Hendricks, J. W., & Peres, S. C.… Continue reading Safe As 30: A better way to think about procedures – resources for action
Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review
This systematic review covers strategies and tools used in healthcare patient safety for learning from normal work and Safety-II. 22 articles met inclusion. For background: · In healthcare “underreporting is highly prevalent, and is linked to, among other things, shaming and blaming mentality, insufficient visible measures and inadequate communication about errors” · “most reporting systems… Continue reading Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review
Root-Causal Factors: Uncovering the Hows & Whys of Incidents
This 2016 article from Fred Manuele explores some facets of causality in investigations. It’s based mainly on two key sources: Hollnagel’s 2004 ‘Barriers and accident prevention’ and Dekker’s 2006 ‘Field Guide to Understanding Human Error’. Won’t be much new for most but has some nice arguments from authors like Hollnagel, Dekker and Leveson. First he… Continue reading Root-Causal Factors: Uncovering the Hows & Whys of Incidents
Designing work systems for resilient performance: insights from resilience engineering
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
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 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
Identification of management traits related to human factors in new views of safety approaches
This paper from Leônidas Brasileiro and colleagues evaluated common attributes across approaches grouped under ‘New View’. i.e. HRO, S-II, SD, RE & HOP – they used both literature and Delphi method. Not a summary since you can read the full paper. It’s an accessible read if you’re keen to quickly understand some key differences and… Continue reading Identification of management traits related to human factors in new views of safety approaches
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