Can Safety-II principles expand learning within investigations? This article proposes a Safety-II framed incident review model for healthcare capturing WAI (work-as-imagined), WAD (work-as-done) and WAE (work-as-experienced). Shared under an open access licence. PS. Check out my YouTube and recent Critical Control / barrier vid: https://youtube.com/@safe_as_pod?si=iUaDPJynPemQRZhY Shout a coffee: https://buymeacoffee.com/benhutchinson Extracts: · “A foundational question remains unresolved:… Continue reading Rethinking learning from incidents in healthcare: a Safety-II model integrating work-as-imagined, work-as-done, and work-as-experienced
Tag: human and organizational performance
Challenges in building resilience engineering (RE) and adaptive capacity: A field study in a chemical plant
Can a complex system effectively navigate risk if it only understands failure in hindsight? This study explores the challenges of building adaptive capacity from a resilience engineering perspective in a chemical plant. On-site observations & interviews were used. PS. Check out my YouTube and recent Critical Control / barrier vid: https://youtube.com/@safe_as_pod?si=iUaDPJynPemQRZhY Shout a coffee: https://buymeacoffee.com/benhutchinson… Continue reading Challenges in building resilience engineering (RE) and adaptive capacity: A field study in a chemical plant
HOP improves learning and reduces quality deviations – new research
Does HOP improve organisational learning behaviours and reduce quality deviations? It turns out, probably. This Master’s thesis from Chris Mastrangelo studied the effects of HOP principles on learning-behaviours, multi‑year trends in deviations, root‑cause classifications, corrective and preventive actions (CAPAs), and Human Performance Assessment (HPA) maturity assessments. Thesis link in comments. The HOP adoption was also… Continue reading HOP improves learning and reduces quality deviations – new research
Resilient health and safety performance on construction sites from a safety-II perspective
“These findings .. emphasizes that resilience stems from dynamic, iterative practices that foster adaptive capacity” How do construction management practices influence resilient health and safety performance? Shared under an open access licence. PS. Check out my YouTube: https://youtube.com/@safe_as_pod?si=iUaDPJynPemQRZhY Extracts: · “Instead of implementing proactive interventions that address planning deficiencies, poor coordination, and organizational decision-making under dynamic… Continue reading Resilient health and safety performance on construction sites from a safety-II perspective
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
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
SafetyInsights.org 