Conventional logic suggests that we fix the gaps that we find in investigations. But is this the case? Is the investigation process more a game of sociopolitical whack-a-mole, finding and fixing the things that are easily solved or understandable, or tolerable to the organisation? Ref: Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you… Continue reading Safe AF ep #5: Is what we find in investigations, what we fix?
Tag: safety-2
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
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
Unveiling Untapped Potential: Leveraging Accident Narratives for Enhanced Construction Safety Management
This study explored the value and insights derived from investigation reports, comparing tabulated data vs extracted narratives. It was interested in what sorts of trends and insights about risk factors could be derived from either data stream. Their method to extract the info was tested against 400 OSHA reports. For context: · Tabular data is… Continue reading Unveiling Untapped Potential: Leveraging Accident Narratives for Enhanced Construction Safety Management
Escaping Failures of Foresight
An interesting discussion paper from David Woods, in response to a paper from Andrew Hopkins discussing process safety indicators (see my article from a few weeks back). ** I haven’t done a good job of this – so suggest you read the original paper. You might want a strong coffee. Woods takes a bit of… Continue reading Escaping Failures of Foresight
The harms of promoting ‘Zero Harm’
This brief editorial discussed some challenges to zero harm approaches (‘absolute safety’) in healthcare. I particularly liked how the author argued that not only is zero harm not attainable, in an absolute sense, but “is unknowable”. Some points: · The authors encourage shifting away from ‘absolute safety’ “towards doing a better job of actively managing risk,… Continue reading The harms of promoting ‘Zero Harm’
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