Does the limited empirical interventional evidence underpinning New View / HOP / Safety-II approaches challenge their credibility? Here Dr Drew Rae unpacks his perspective on how this is often framed as a confused question. We also discuss the limited evidence behind Risk Matrices, which prompts the foundational question: what are they actually used for?
Tag: hop
Is ‘safety’ the presence of capacities?
What is your definition of ‘safety’? For some, safety is defined as the presence of capacities. Here, Drew Rae discusses his thoughts, and scientific logics, of this definition. #safety #hse #risk #science #safetyscience #safetyii
Safer Systems: People Training or System Tuning?
Hollnagel discusses the role of training in complex systems. Shared under open access licence. PS. Check out my YouTube channel: Safe As: A thrifty analysis of safety, AI and risk – YouTube Extracts:· “Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like… Continue reading Safer Systems: People Training or System Tuning?
Safety-I Versus Safety-II: A Mixed-Methods Study Revealing the Imbalance of Approaches in Primary Care Medication Safety
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
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
SafetyInsights.org 