The effects of power, leadership and psychological safety on resident event reporting

This open access paper explored the relationships between power distance and leader inclusiveness on psychological safety, and resident willingness to report adverse events. Sample was 106 residents in a US teaching hospital. Key findings: ·      Perceived power distance and leader inclusiveness both significantly predicted psychological safety ·      This in turn significantly predicted intention to report adverse events…

Auditism: Symptoms, Safety Consequences, Causes, and Cure

This chapter explores an organisational “imagined disease”, termed by the author as “auditism” [** I love this term]. I’ll be using a lot of direct quotes. I haven’t done a good job of this, so recommend you check out the chapter. It’s noted that we’re surrounded by auditism and have been convinced that what we…

Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology

This study explored how psychological safety (PS) affects near-miss reporting and learning in radiation oncology. They note that near misses contain contrasting cues highlighting both resilience and vulnerability. Based on prior work from Dillon, Tinsley et al., they note that a near miss may have cues of resilience (“we avoided failure”) and vulnerability (“we nearly…

Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures

Another absolute banger of a paper co-authored by one of my favourite authors – the late, great Bob Wears. As is often the case with Bob and co’s papers, these brief 3-4 pagers are the most densely packed and most difficult to summarise. I’m using a lot of direct quotes because the language is poetic,…

Crew Resource Management training and patient mortality: no significant effects

What impact does a comprehensive Crew Resource Management (CRM) training program, and subsequent practices, have on in-hospital patient mortality and failure to rescue? Not a lot, according to another upcoming study. Two hospitals, one control and one intervention, were compared after 3 years. The CRM program in the intervention hospital consisted of a 4-hr comprehensive…

Organisational disease: auditism. A condition where ill-fitting management systems and practices are propagated

An upcoming summary explores an organisational “imagined disease”, termed by the author as “auditism” [** I love this term]. It’s noted that we’re surrounded by auditism, and have been convinced that what we do at work must be documented, to “prove that we did what we should have done”. Auditism is said to emerge “when…

Unintended consequences of management strategies for improving labor productivity in construction industry

This studied the impact various management strategies to boost labour productivity have on safety. Strategies were human resource (HR) and construction management (CM) related and included a large number of strategies (48 practices; shown below).  Survey data was collected from 111 general construction projects. The importance of this is that construction is not just one…

Shift from human-focused investigations to system focused learning and sensemaking in US Forestry

An interesting read from Ivan Pupulidy describing the shift in the US Forestry Service’s approach to serious incident investigation from their prior method to that of a Learning Review. There’s a lot here (210 page dissertation), but the summary provides a useful collection of key assumptions that “bound” their thinking to less effective ways to…

Violation with concerns of safety: A study on non-compliant behavior and the antecedent and consequent effects in power grid construction

This study explored the links between non-compliant behaviour (procedural departures but accounting for risk perception), safety climate and safety leadership. 390 workers and their supervisors in a Chinese power grid construction firm were sampled. Note: While this study talks of compliance (and associating rule following as ‘correct’ or ‘compliant’) and violations (I’ve never liked ‘violation’…

Major accident audit failures p.2: A failure to manage and a failure to focus

Our recent study of 44 major or fatal accident reports in the process, chemical, pipeline, mining, oil & gas industries explored how audits failed prior to the accident (according to the investigation). In the first post (link below), I covered the first two categories of audit failures (1 Audits involve a failure to understand, 2…