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
Tag: normal work
Importance of understanding work-as-done: Fascinating extracts from CEO due diligence prosecution
Understanding work-as-done seen as critical for PCBUs and CEOs/Officers, according to this prosecution of a CEO who failed to exercise due diligence relating to a work-related fatality (Ports of Auckland Limited (POAL). Extracts: · “[234] “Work as done” is the reality of work as it is actually carried out by the workers on the shop floor.… Continue reading Importance of understanding work-as-done: Fascinating extracts from CEO due diligence prosecution
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
Open-access healthcare debriefing videos need to incorporate more Safety-II learnings
Are Safety-II concepts used in debriefing? This explored the language and framings used in open access debriefing videos, to ascertain whether the questioning probes deeper into S-I (focus on failure/error) or S-II (focus on normal work, variability, success) questioning. Note: Only 7 videos met inclusion for transcription/evaluation. They note that learning from success isn’t “uncommon… Continue reading Open-access healthcare debriefing videos need to incorporate more Safety-II learnings
Compendium: Learning and improvement without incidents
Here’s a mini-compendium of…well, probably a lot of stuff with only a tenuous link to ‘learning’. I tried to focus on learning that doesn’t require incidents, but you’ll find those here, too. There’s >100 articles, mostly full-text. I think I went overboard. Unfortunately, it’s barely sorted. It includes: Shout me a coffee Learning Strengths &… Continue reading Compendium: Learning and improvement without incidents
SafetyInsights.org 