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

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?

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

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