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
Tag: safety-ii
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
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
Foundations of Safety Science: Resilience Engineering and safety as the presence of capacities
More extracts from Foundations of Safety Science, this time from Ch.11 on Resilience Engineering and the adaptive perspective. This is 1 of probably 2 or 3 more posts. Some extracts: “Resilience engineering is based on the premise that we are not custodians of already safe systems. Complex systems do not allow us to draw up… Continue reading Foundations of Safety Science: Resilience Engineering and safety as the presence of capacities
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
Interventions and measurements of highly reliable/resilient organization implementations: A literature review
This reviewed literature on High Reliability Organisations (HRO) and similar approaches in Resilience Engineering (RE) from 1981 to 2020 to determine its impact. 34 articles out of 1400 met inclusion. For background: · “There is a class of organizations that can do catastrophic harm to themselves and a larger public” and within this set, there’s… Continue reading Interventions and measurements of highly reliable/resilient organization implementations: A literature review
When Things Go Right: Safety II in an Academic Emergency Department
This study explored variability and ED clinician proactive adaptations in order to enhance safety in the face of demands and pressures. Data was based on a cross-sectional survey. Background: · Patient safety, according to one agency, is defined as “the prevention of errors, injury, or other preventable harm and reduction of unnecessary harm” · They… Continue reading When Things Go Right: Safety II in an Academic Emergency Department
Human Factors and New Views of safety applied to management systems: A systematic literature review
This conference paper from Leonidas Brasileiro, Julio Cesar de Faria Alvim Wasserman and Gilson Brito Alves Lima may interest you. It explored how different concepts under HF and New View have been applied to management systems via literature review (2000 – 2023). Note: I’ve skipped a lot, so check out the paper. Some extracts: · “New… Continue reading Human Factors and New Views of safety applied to management systems: A systematic literature review
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’
Doctors are more dangerous than gun owners: a rejoinder to error counting
This 2006 paper from Sid Dekker critically challenges the assumptions underlying “error counting” in safety. Some points: (Not a summary) Error background Error counts by organisations are seen to have numerous benefits – providing “an immediate, numeric estimate of the probability of accidental death, injury or other undesirable event” However, categorising errors requires “a number… Continue reading Doctors are more dangerous than gun owners: a rejoinder to error counting
