An interesting paper exploring the use of Safety-II inspired debriefs, learning from successful performance. They used cognitive task analysis techniques. Not a summary, but it’s open access and really brief – so check it out 👍 Extracts: · “simulation cases are often deliberately designed to push learners to their zone of proximal development .. where perfect… Continue reading ‘They didn’t do anything wrong! What will I talk about?’ Applying the principles of cognitive task analysis to debriefing positive performance
Tag: resilience engineering
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?
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
Hollnagel on “Human error”: error as cause, process or outcome
Not much to say – some extracts from a 2007 chapter from Erik Hollnagel, unpacking whether we really need “human error”? I knocked the summary up last night and will probably post in the next couple of weeks. Oh man, I need to give up on chapters…what a slog. He argues: · Human error “is not… Continue reading Hollnagel on “Human error”: error as cause, process or outcome
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
Time pressure in surgical teams, a help or a hindrance to patient safety?
I found this an interesting and brief read about the mindful routines of operating room staff, using a naturalistic decision making approach. Extracts: Ref: van Harten, A., Niessen, T. J., Koksma, J. J., Gooszen, H. G., & Abma, T. A. (2025). Heliyon. Shout me a coffee Study link: https://doi.org/10.1016/j.heliyon.2025.e41967 Shout me a coffee: https://buymeacoffee.com/benhutchinson LinkedIn post:… Continue reading Time pressure in surgical teams, a help or a hindrance to patient safety?
Learning from normal work: How to Proactively Reduce Risk When Nothing Goes Wrong
An interesting article from Marcin Nazaruk, exploring learning from everyday work. Skipping a bit, so check out the full article. First he says that while it’s important to learn from failure “it is too late”. For one, diminishing incident rates “can no longer accurately reflect safety performance … and simply focusing on behaviours and unsafe… Continue reading Learning from normal work: How to Proactively Reduce Risk When Nothing Goes Wrong
Procedure excellence: Changing paradigms to enable human reliability
This paper from Elliot Wolf-Stokes and Rob Fisher may interest peeps – around orientating towards operational excellence. Covers a lot of ground – systemic drivers to procedural departures, error drivers in written guidance, mental models, enablers of human reliability and more. I’ve skipped HEAPS, so just a few extracts (link to full paper in comments):… Continue reading Procedure excellence: Changing paradigms to enable human reliability
Foundations of Safety Science: Resilience Engineering and 3 analytical traps for resilience practitioners
Post 3 from ch.11 of the Foundations of Safety Science, exploring Resilience Engineering (RE) and the adaptive perspectives. This part focuses on 3 analytical traps for resilience practitioners/scholars to be cognisant of (you may recognise these from Johan Bergstrom’s youtube vid – link in comments). Extracts: · The first trap is the reductionist trap · Whereas “the… Continue reading Foundations of Safety Science: Resilience Engineering and 3 analytical traps for resilience practitioners
Foundation of Safety Science: Resilience Engineering and complex systems pt2
Post 2 from ch.11 of the Foundations of Safety Science, exploring Resilience Engineering (RE) and the adaptive perspectives. Some extracts: · RE sees failures not necessarily as breakdowns or malfunctioning of normal functions, but “the converse of the adaptations necessary to cope with the real world complexity” · Performance of individuals and organisations across all level “must… Continue reading Foundation of Safety Science: Resilience Engineering and complex systems pt2
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