In the lead up to next week’s compendium on systems thinking, here’s a banger from Donella Meadows. She explores system leverage points. Not a summary, but some extracts: · Leverage points are “places within a complex system .. where a small shift in one thing can produce big changes in everything” · The “state of the system”… Continue reading Leverage points to intervene in a system – Donella Meadows
Tag: technology
Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
This systematic review evaluated evidence for what support staff want vs what they receive, and whether the support is effective. 99 studies were included. Some extracts: · PSI (patient safety incident) lead to emotional shame, guilt, anger, shock, depression, fear, flashbacks, helplessness, fatigue, withdrawal and more · The three most desired support types staff want before and… Continue reading Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A 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
The difference between ‘making do’ and resilience in complex systems
This paper explores the difference between ‘making do’ and resilience. Not a summary, but a few extracts: · Making do has been defined, from a waste perspective as “a situation where a task is started without all its standard inputs, or the execution of a task is continued although the availability of at least one standard… Continue reading The difference between ‘making do’ and resilience in complex systems
‘They didn’t do anything wrong! What will I talk about?’ Applying the principles of cognitive task analysis to debriefing positive performance
An interesting paper exploring the use of Safety-II inspired debriefs, learning from successful performance. They used cognitive task analysis techniques. Not a summary, but it’s open access and really brief – so check it out 👍 Extracts: · “simulation cases are often deliberately designed to push learners to their zone of proximal development .. where perfect… Continue reading ‘They didn’t do anything wrong! What will I talk about?’ Applying the principles of cognitive task analysis to debriefing positive performance
The rise of learning teams: How organisations in Australia are adopting group learning practices for safety improvement
This Master’s thesis from Andrew Barrett explored group learning practices, like learning teams, for safety improvement. Specifically, he studied the following question via institutional ethnographic interviews: · how are organisations in Australia adopting group learning practices for safety improvement? Way too much to cover – so check out the thesis. Some background extracts: · “Safety… Continue reading The rise of learning teams: How organisations in Australia are adopting group learning practices for safety improvement
Resilient Procedures: Oxymoron or Innovation?
An interesting chapter from the late Bob Wears around ‘resilient procedures’. I’ve skipped heaps. They specifically explore: · what baggage tends to accompany procedures · what is bad about procedures · what is good about them · how procedures might be designed to support or even enhance resilience, instead of degrading it. Procedures are said… Continue reading Resilient Procedures: Oxymoron or Innovation?
Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
This study unpacked what investigators look at and how they construct causes in high-speed workboats. It employed a Safety-II / HOP / HF perspective. Tl;dr: human factors are poorly evaluated and largely seen as individual-level factors. Some extracts: · “Although the analysis focused on negative observations, it also identified HFs that supported the activity” · “Many pivotal… Continue reading Human factor analysis of cockpit work incidents in high-speed workboats: the mystery hidden between the lines
The mixed blessing of risk defences and redundancy: James Reason
A few random extracts from James Reason’s timelessly awesome Managing the Risks of Organizational accidents. (Note: This isn’t an endorsement of the somewhat linearity of defences-in-depth, since we have evidence that emergent behaviour can playout in reality and with equifinality etc) There’s hundreds of things I could extract (and maybe will in time), but here’s… Continue reading The mixed blessing of risk defences and redundancy: James Reason
“I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
“Every intelligent system makes errors”, so said Gerd Gigerenzer. Here’s a couple of page extracts from a 2005 paper. Not sure if I’ll summarise it or not (it’s really interesting, but tough to capture in a summary…) The paper: · Challenges the rationalistic and normative ideal as cognition as purely a logical and rational one, ignoring… Continue reading “I think, therefore I err”: An article about ‘good errors’, heuristics and intelligent systems
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