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Just Culture

Author: Sidney Dekker
Publisher: Ashgate Publishing, Ltd.
ISBN: 1409440605
Size: 64.89 MB
Format: PDF
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While many organizations see the value of creating a just culture they struggle when it comes to developing it. In this Second Edition, Dekker expands his views, additionally tackling the key issue of how justice is created inside organizations. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas.

Patient Safety

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 143985226X
Size: 55.64 MB
Format: PDF
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Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues. People often think, understandably, that safety lies mainly in the hands through which care ultimately flows to the patient—those who are closest to the patient, whose decisions can mean the difference between life and death, between health and morbidity. The human factors approach refuses to lay the responsibility for safety and risk solely at the feet of people at the sharp end. That is where we should intervene to make things safer, to tighten practice, to focus attention, to remind people to be careful, to impose rules and guidelines. The book defines an approach that looks relentlessly for sources of safety and risk everywhere in the system—the designs of devices; the teamwork and coordination between different practitioners; their communication across hierarchical and gender boundaries; the cognitive processes of individuals; the organization that surrounds, constrains, and empowers them; the economic and human resources offered; the technology available; the political landscape; and even the culture of the place. The breadth of the human factors approach is itself testimony to the realization that there are no easy answers or silver bullets for resolving the issues in patient safety. A user-friendly introduction to the approach, this book takes the complexity of health care seriously and doesn’t over simplify the problem. It demonstrates what the approach does do, that is offer the substance and guidance to consider the issues in all their nuance and complexity.

The Field Guide To Understanding Human Error

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351889753
Size: 51.12 MB
Format: PDF, ePub, Docs
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When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.

Managing The Risks Of Organizational Accidents

Author: James Reason
Publisher: Routledge
ISBN: 1134855354
Size: 28.48 MB
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Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

Pre Accident Investigations

Author: Dr Todd Conklin
Publisher: Ashgate Publishing, Ltd.
ISBN: 1409483541
Size: 25.48 MB
Format: PDF, ePub, Docs
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This book is a set of new skills written for the managers that drive safety in their workplace. This is Human Performance theory made simple. If you are starting a new program, revamping an old program, or simply interested in understanding more about safety performance, this guide will be extremely helpful.

Drift Into Failure

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351942913
Size: 46.84 MB
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What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.

Second Victim

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 146658341X
Size: 51.82 MB
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How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims’. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book

Safety Differently

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1482242001
Size: 41.56 MB
Format: PDF, Mobi
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The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resulted in new roles, decisions, and vulnerabilities whilst practitioners are also faced with new levels of complexity, adaptation, and constraints. It is becoming increasingly apparent that conventional approaches to safety and human factors are not equipped to cope with these challenges and that a new era in safety is necessary. In addition to new material covering changes in the field during the past decade, the book takes a new approach to discussing safety. The previous edition looked critically at the answers human factors would typically provide and compared/contrasted them with current research and insights at that time. The edition explains how to turn safety from a bureaucratic accountability back into an ethical responsibility for those who do our dangerous work, and how to embrace the human factor not as a problem to control, but as a solution to harness. See What’s in the New Edition: New approach reflects changes in the field Updated coverage of system safety and technology changes Latest human factors/ergonomics research applicable to safety Organizations, companies, and industries are faced with new demands and pressures resulting from the dynamics and nature of the modern marketplace and from the development and introduction of new technologies. This new era calls for a different kind of safety thinking, a thinking that sees people as the source of diversity, insight, creativity, and wisdom about safety, not as the source of risk that undermines an otherwise safe system. It calls for a kind of thinking that is quicker to trust people and mistrust bureaucracy, and that is more committed to actually preventing harm than to looking good. This book takes a forward-looking and assertively progressive view that prepares you to resolve current safety issues in any field.

Human Error

Author: James Reason
Publisher: Cambridge University Press
ISBN: 9780521314190
Size: 63.11 MB
Format: PDF, ePub, Mobi
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This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.

Influencing The Quality Risk And Safety Movement In Healthcare

Author: Kim Sears
Publisher: CRC Press
ISBN: 1317116925
Size: 31.14 MB
Format: PDF, ePub, Docs
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Influencing the Quality, Risk and Safety Movement in Healthcare explores the inner workings of some of the most influential minds in healthcare quality, risk and safety. The book was created in cooperation with the Master of Science in Healthcare Quality graduate program, developed and delivered by Queen’s University, Canada. This is the only standalone interdisciplinary Master of Science graduate degree in Healthcare Quality in North America that focuses on creating tomorrow’s healthcare leaders. Following a one-to-one collaboration between each leader in healthcare with a dedicated learner of the MSc(HQ), readers are presented with a synopsis of the leader’s work followed by an in-depth interview with him or her. Interviews center around the leaders’ contributions to and thoughts on quality, risk and safety in healthcare, dealing with topics such as the development of their body of work, their greatest achievements, what they wish they could change, and future direction of quality, risk and safety, etc. The book provides a unique and highly accessible view into how and why the science of healthcare quality has developed, as well as giving a first-hand account of the founders and key players in the movement. It will offer valuable insights to any undergraduate/graduate class with an interest in healthcare, as well as professionals working within any of the many disciplines that can influence the healthcare system.