From punitive action to confidential reporting: A longitudinal study of organizational learning

This study explored the shift from a punitive to non-punitive reporting approach in a hospital over 2 years, while assessing the capacity and success of learning. Before the transition, an employee involved in an incident reported the event to his/her manager, who would then devise improvements (mostly in the form of a reminder to watch…

‘Mistaking error’ – an earlier paper from David Woods & Richard Cook

A banger from Woods and Cook exploring the notions of ‘error’. Originally from 2004 and updated in 2012. I’ve skipped heaps – so check out the full paper. They argue that: ·        They refer to the progressive, adaptive perspective as the ‘New Look’ ·        Error is used inconsistently, since it can mean: o  1) a cause of failure,…

Safe Work Method Statements a “shambolic mess … with incoherent risk assessments built off the back of equally incoherent risk matrices” – Greg Smith, Proving Safety

Well, Greg Smith doesn’t mince words about the application of Safe Work Method Statements (SWMS) – being typically a “shambolic mess … with incoherent risk assessments built off the back of equally incoherent risk matrices”. He also argues that they fail to properly address issues of criticality, where the management of high-risk work activities is…

Blame Conformity: Leading Eyewitness Statements can Influence Attributions of Blame for an Accident

This study explored whether attributions of blame for an incident can be shifted between people due to leading eyewitness statement. The method had participants watch a video of an accident involving two men and read either a non-leading witness statement that blamed no one for the accident, or a leading eyewitness statement that blamed one…

Reconstructing human contributions to accidents: the new view on error and performance

Another earlier (2002) paper from Sid Dekker. It explores a shift in how the role of people in both (sometimes) failure, but usually success, is seen. Of course, there’s been a lot more since written on this; but still an interesting read. Personally, I’m less interested in the new vs old arguments; but the stuff…

Organisational learning and the shift to a non-punitive reporting approach

What is the relationship between learning and a shift to a non-punitive reporting approach? This 2007 study from Dekker and Laursen explored this question. Over a period of two years, a transition occurred in a hospital in how reporting was undertaken, and how managers responded. Before the transition, an employee involved in an incident reported…

Organisations’ have no memory: Trevor Kletz on building collective mindfulness for major accident prevention

I’ve long been fascinated by this idea from Trevor Kletz (I love his work) about how organisations ‘have no memory’, and a way to maintain this collective human capability is to mark-up critical procedures, standards etc. with the reasons why those specifications exist. Examples would be critical investigation findings, or findings from experience, HAZOPs, and…

Breaking the rules: understanding non-compliance with policies and guidelines

This was a brief discussion paper about why people don’t always follow rules, but from the perspective of healthcare practitioners within the NHS. The findings themselves aren’t new or unique to healthcare but it’s good to see the perspective of the people that are required to follow all of the guidelines. I think many of…

Safe operation as a social construct

This 1999 paper is an interesting read, exploring the social nature of ‘safety’. Some points I liked are: ·        “operational safety is more than the management or avoidance of risk or error…[but rather] an ongoing intersubjective construct not readily measured in terms of safety cultures, structures, functions, or other commonly used descriptors of technical or organizational…

The effects of recent sleep duration, sleep quality, and current sleepiness on eyewitness memory

I found this interesting – prior night sleep quality affects the recollection of details from events. This study assessed the ability of people to recall central and peripheral details about a crime that they witnessed (via video). Sleep length and sleepiness was assessed via self-report questionnaire (so, not the most accurate for sleep…) They found that:…