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
Tag: safety-ii
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
The human factor: Pursuing success and averting drift into failure – YT video, Sidney Dekker
A 2018 presentation from Sid Dekker on success and drift into failure. One of many such, and no particular reason why this one over any other. Sid starts with an example he heard, supporting the bad apple thesis: “just get rid of the nurses who make mistakes and all will be a lot safer” “Now… Continue reading The human factor: Pursuing success and averting drift into failure – YT video, Sidney Dekker
Compendium of Nancy Leveson: STAMP, STPA, CAST and Systems Thinking
Although I don’t often mention or post about Leveson’s work, she’s probably been the most influential thinker on my approach after Barry Turner. So here is a mini-compendium covering some of Leveson’s work. Feel free to shout a coffee if you’d like to support the growth of my site: https://direct.mit.edu/books/oa-monograph/2908/Engineering-a-Safer-WorldSystems-Thinking-Applied https://doi.org/10.1177/0170840608101478 https://doi.org/10.1145/7474.7528 http://therm.ward.bay.wiki.org/assets/pages/documents-archived/safety-3.pdf http://sunnyday.mit.edu/papers/Rasmussen-Legacy.pdf https://www.tandfonline.com/doi/pdf/10.1080/00140139.2015.1015623… Continue reading Compendium of Nancy Leveson: STAMP, STPA, CAST and Systems Thinking
Root-Causal Factors: Uncovering the Hows & Whys of Incidents
This 2016 article from Fred Manuele explores some facets of causality in investigations. It’s based mainly on two key sources: Hollnagel’s 2004 ‘Barriers and accident prevention’ and Dekker’s 2006 ‘Field Guide to Understanding Human Error’. Won’t be much new for most but has some nice arguments from authors like Hollnagel, Dekker and Leveson. First he… Continue reading Root-Causal Factors: Uncovering the Hows & Whys of Incidents
Designing work systems for resilient performance: insights from resilience engineering
This explored Design for Resilient Performance (DfRP) via their framework. Not a summary – just a few extracts, but maybe I’ll summarise it in the future. Some extracts: · “Resilient performance (RP) is a socio-technical system’s ability to adjust its functioning prior to, during, or following changes and disturbances, thereby sustaining operations under both expected and… Continue reading Designing work systems for resilient performance: insights from resilience engineering
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
The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
This was a really brief discussion paper from Dekker and Leveson, covering systems thinking in medicine. Three parts – see comments. Nothing new for most, but they cover: · “The ‘systems approach’ to patient safety has recently led to questions about its ethics and practical utility” · E.g. A recent paper from a retired neurosurgeon questioned systems… Continue reading The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
SafetyInsights.org 