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
Tag: sidney-dekker
“there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Extracts from Dekker’s work about the ontological and empirical shakiness of ‘root causes’. I’ve taken material from two versions of The Field Guide to Understanding Human Error (Investigations). In Dekker’s view: · “There is no ‘root’ cause” (or ‘root causes’) · Given the multiple angles and interactions in complex systems, you “can really construct “causes” from everywhere”… Continue reading “there is no such thing as a root cause [and therefore] there is technically no such thing as the beginning of a mishap” — Dekker
Forgiveness as morally serious response to errors in healthcare: A narrative review
An interesting and recent discussion paper from Sidney Dekker, exploring forgiveness as a ‘morally serious response’ to incidents, as opposed to retributive approaches. Tl;dr: · “while retribution addresses certain ethical concerns, it is incomplete and can be counterproductive, particularly for patient safety and organizational learning” · “Systems that focus primarily on individual blame risk fostering… Continue reading Forgiveness as morally serious response to errors in healthcare: A narrative review
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
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
