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
Tag: hop
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
Human Error: Trick or Treat?
This 2007 chapter from Hollnagel unpacked whether we really need the concept of “human error” (HE). It’s a whole chapter, so I’ve skipped HEAPS. Tl;dr according to Hollnagel: · “there is no need of a theory of “human error” because the observed discrepancies in performance should be explained by a theory of normal performance rather… Continue reading Human Error: Trick or Treat?
Human Success: Old wine in new bottles, or a shift of mindset for HRA in an automated world?
A really interesting conference paper from Andreas Bye, discussing whether shifting Human Reliability Analysis (HRA) terminology from human error to human success would help alleviate some of the blame-connotations. Also discussed is the human role in automated systems. It was meant to be a mini-post with a few dot-points and a couple of images, but… Continue reading Human Success: Old wine in new bottles, or a shift of mindset for HRA in an automated world?
Analyzing Procedure Performance using Abstraction Hierarchy: Implications of Designing Procedures for High-risk Process Operations
This paper explored the use of procedures and operator performance from the perspective of work domain analysis/abstraction hierarchy. I’ve skipped heaps – the ‘doing’ part of the abstraction hierarchy, but their descriptions of the problem and the discussion had some gold. For context: · Procedural issues have been linked in a number of major accidents… Continue reading Analyzing Procedure Performance using Abstraction Hierarchy: Implications of Designing Procedures for High-risk Process Operations
The rise of learning teams: How organisations in Australia are adopting group learning practices for safety improvement
This Master’s thesis from Andrew Barrett explored group learning practices, like learning teams, for safety improvement. Specifically, he studied the following question via institutional ethnographic interviews: · how are organisations in Australia adopting group learning practices for safety improvement? Way too much to cover – so check out the thesis. Some background extracts: · “Safety… Continue reading The rise of learning teams: How organisations in Australia are adopting group learning practices for safety improvement
Resilient Procedures: Oxymoron or Innovation?
An interesting chapter from the late Bob Wears around ‘resilient procedures’. I’ve skipped heaps. They specifically explore: · what baggage tends to accompany procedures · what is bad about procedures · what is good about them · how procedures might be designed to support or even enhance resilience, instead of degrading it. Procedures are said… Continue reading Resilient Procedures: Oxymoron or Innovation?
“The fetishism of scientific management” – a 1912 criticism
An interesting critique of Scientific Management approach from 1912. Great title – ‘fetishism of scientific management’. The author argues that: · Scientific Management isn’t even that ‘new’, and is kind of what they’ve always done (…where have we heard that argument before?) · Says it takes away from the craftsmanship of people and that people are the… Continue reading “The fetishism of scientific management” – a 1912 criticism
Human Performance Tools: Engaging Workers as the Best Defense Against Errors & Error Precursors
This article covered a more progressive view on human performance, with suggestions on some tools. Too much to cover, so just a few points. They start by saying to consider three truisms: “To err is human. Workers are fallible. Errors are inevitable (as well as predictable)”. These are fundamentals to understanding the human performance approach… Continue reading Human Performance Tools: Engaging Workers as the Best Defense Against Errors & Error Precursors
Contextualising new safety paradigms: A study in a large Australian construction company
This study explored the presence, implementation, appetite and feasibility of 12 principles representing “new safety paradigms”. It involved focus groups with 53 participants and a cross-sectional survey of 514 employees. I’ve skipped HEAPS (actually, the entire results section – so check out the full paper). Background: · “The review by Karanikas et al. (2022) revealed… Continue reading Contextualising new safety paradigms: A study in a large Australian construction company
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