Extracts from a paper that studied medication safety in primary care from both a Safety-I and Safety-II lens – using “medication management in the wild” as their data. · 2 decades after the ‘To Err is Human’ report has “given way to hard bitten realism that there has been little measurable improvement in the overall rates… Continue reading Safety-I Versus Safety-II: A Mixed-Methods Study Revealing the Imbalance of Approaches in Primary Care Medication Safety
Tag: safety-ii
Safe As 38: 4Ds – Dumb, Dangerous, Different, Difficult – for learning (quickisode)
This quickisode unpacks the 4D method for learning: Dumb, Dangerous, Different, Difficult. The source is Sutton et al. 2023. 4Ds for HOP and Learning Teams: A practical how-to guide to facilitate learning from everyday work, critical and dynamic risks with the 4Ds. Spotify: https://open.spotify.com/episode/5kVSsQBISQK3vMREbUGExv?si=LOvB1DE1SfCE-8E7uYSK_Q Apple: https://podcasts.apple.com/us/podcast/e38-4ds-dumb-dangerous-different-difficult-for-learning/id1819811788?i=1000727889641 Make sure to subscribe to Safe As on Spotify/Apple,… Continue reading Safe As 38: 4Ds – Dumb, Dangerous, Different, Difficult – for learning (quickisode)
Learning from normal work in complex sociotechnical system—Case in midstream operation
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
Safe As week in review – 22, 23, 24: Zombie leaders, Safety-II debriefs, and causal illusions of leadership styles
Safe As week in review: E22: Zombie leadership … being “dead ideas [about leadership] that still walk amongst us”. Zombie leadership is covered by several axioms: images 1 and 2. These dead ideas, being already dead can “absorb all kinds of damage and keep lumbering on towards their targets”; that is, difficult to slay. Zombie… Continue reading Safe As week in review – 22, 23, 24: Zombie leaders, Safety-II debriefs, and causal illusions of leadership styles
Safe As ep 23 (quickisode 2): Safety-II debrief tool
Want to add a garnish of Safety-II inspired thinking into debriefs? Check out this 4 min quickisode. Today’s article is: Bentley, S. K., McNamara, S., Meguerdichian, M., Walker, K., Patterson, M., & Bajaj, K. (2021). Debrief it all: a tool for inclusion of Safety-II. Advances in Simulation, 6(1), 9. Spotify: https://open.spotify.com/episode/54H6o9h4ZiSSlgVFOjAqC6?si=kY5uaG1sRlyCW10ylAsmgw Apple: https://spotifycreators-web.app.link/e/ukQV4y4RRVb Make sure to subscribe… Continue reading Safe As ep 23 (quickisode 2): Safety-II debrief tool
The Folly of Safety-III
Hollnagel’s response to some of the recent (and somewhat bizarre) articles on ‘Safety-III’. Spoiler: It’s not charitable. I’m relying on a lot of direct quotes. Providing context, Hollnagel argues: · Introduction of Safety-I and Safety-II (SI / SII) to characterise two opposite means of safety was “met with surprisingly large interest” and “also with some… Continue reading The Folly of Safety-III
Safe AF ep #5: Is what we find in investigations, what we fix?
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?
Designing for resilient performance & worker participation: design principles
This review explored how to design for worker participation, drawing on the design of resilient systems. Not much to say – the extracts cover core resilient design principles. Some extracts to contextualise the images: · Participation refers to “the worker’s influence in decision-making related to safety, involving information sharing between people” · “Design for resilient performance Design… Continue reading Designing for resilient performance & worker participation: design principles
Management of safety rules and procedures
Really interesting report from Hale, Borys & Else about the nuances of rules, and contrasting model 1 / model 2. [* Check out this week’s compendium dedicated to Hale & Hopkins, link below] A few extracts: · A classic Dutch railways study showed that 3% of workers used rules often and 50% almost never, 47% found… Continue reading Management of safety rules and procedures
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
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