Seems fitting to cover some work from James Reason and to reflect on his enduring impact on our professional work, thinking and models. I’ve focused more on articles I’ve summarised or posted an image extract of, or could find a full-text article for. It’s NOT systematic. I’ve also included articles not from Reason but whom… Continue reading A life of Reason: A mini-compendium of James Reason’s contributions
Tag: just-culture
Forgiveness as morally serious response to errors in healthcare: A narrative review
An interesting and recent discussion paper from Sidney Dekker, exploring forgiveness as a ‘morally serious response’ to incidents, as opposed to retributive approaches. Tl;dr: · “while retribution addresses certain ethical concerns, it is incomplete and can be counterproductive, particularly for patient safety and organizational learning” · “Systems that focus primarily on individual blame risk fostering… Continue reading Forgiveness as morally serious response to errors in healthcare: A narrative review
Allocation of Blame After a Safety Incident
This single page conference paper discussed an experiment on how blame is allocated following incidents. The scenario was a “realistic, but fictitious” incident involving a worker (both experienced or not experienced, depending on the scenario), whom is killed when touching an energised bus bar while feeding electrical wire into a pedestal. They systematically manipulated the… Continue reading Allocation of Blame After a Safety Incident
Compendium: Blame, Just Culture & language
Here’s another compendium of articles exploring blame and language in the construction of post-hoc causality explanations, or how blame effects learning and investigations. The other part covers some articles around Just Culture and restorative culture. Note: I’ve mostly focused on articles that I’ve either already summarised or that I could find a full text link… Continue reading Compendium: Blame, Just Culture & language
From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
This 2018 paper explored the effects of a re-designed Just Culture (JC) process in an international energy company. It’s a solid read and worth your time – I’ve had to skip heaps. Providing background: · This organisation started using the James Reason JC framework in 201, but collective experience in the organisation “indicated that the… Continue reading From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
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