The Field Guide To Understanding Human Error

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1351889753
Size: 27.56 MB
Format: PDF
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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 This old view of human error is increasingly outdated and will lead you nowhere.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.

The Field Guide To Understanding Human Error

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1317031830
Size: 60.39 MB
Format: PDF, ePub
View: 1862
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When faced with a ’human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. 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. Building on its successful predecessors, the third edition of The Field Guide to Understanding ’Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a ’human error’ problem, abandon the fallacy of a quick fix. Read this book.

Lean Human Performance Improvement

Author: Jerry L. Harbour
Publisher: CRC Press
ISBN: 1482298821
Size: 30.13 MB
Format: PDF, Mobi
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As companies continue their efforts to improve work performance, they must ensure that their ongoing Lean activities include a healthy appreciation for, and recognition of, human performance. Ignoring the human component of work performance can be a recipe for unnecessary waste, inefficiency, and decreased productivity. Lean Human Performance Improvement presents a broad overview of human performance in the workplace. The author discusses his findings from a broad spectrum of human performance-related fields and diverse industrial sectors (gained by working in the field for over 30 years). Organized in three sections, this book covers understanding human performance, analyzing and improving work productivity, and analyzing and improving quality and safety. The author first develops a fundamental and basic understanding of human performance, then couples that understanding with learning how to analyze and improve human-related work productivity and quality and safety. He also discusses how knowledge and skills transfer from one work setting to another. Intended for Lean Six Sigma team members and human performance improvement practitioners, the book contains multiple examples from diverse work settings to explain key points. It also includes several major case studies. The goal of all examples and case studies is to develop a generic understanding that, in turn, can be successfully applied to any work setting.

Foundations Of Safety Science

Author: Sidney Dekker
Publisher: Routledge
ISBN: 1351059777
Size: 26.17 MB
Format: PDF, ePub, Mobi
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How are today’s ‘hearts and minds’ programs linked to a late-19th century definition of human factors as people’s moral and mental deficits? What do Heinrich’s ‘unsafe acts’ from the 1930’s have in common with the Swiss cheese model of the early 1990’s? Why was the reinvention of human factors in the 1940’s such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? ‘Foundations of Safety Science’ covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today. Features Offers a comprehensive overview of the theoretical foundations of safety science Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use Uses an accessible style, using technical language where necessary Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches

Resilient Health Care Volume 2

Author: Robert L. Wears
Publisher: Ashgate Publishing, Ltd.
ISBN: 1472437845
Size: 28.76 MB
Format: PDF, Kindle
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Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as ‘work-as-imagined’). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work breaks new ground by analysing everyday work situations in primary, secondary, and tertiary care to identify and describe the fundamental strategies that clinicians everywhere have developed and use with a fluency that belies the demands to be resolved and the dilemmas to be balanced. Because everyday clinical work is at the heart of resilience, it is essential to appreciate how it functions, and to understand its characteristics.

Value By Design

Author: Eugene C. Nelson
Publisher: John Wiley & Sons
ISBN: 9780470901359
Size: 28.39 MB
Format: PDF, Mobi
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Value by Design is a practical guide for real-world improvement in clinical microsystems. Clinical microsystem theory, as implemented by the Institute for Healthcare Improvement and health care organizations nationally and internationally, is the foundation of high-performing front line health care teams who achieve exceptional quality and value. These authors combine theory and principles to create a strategic framework and field-tested tools to assess and improve systems of care. Their approach links patients, families, health care professionals and strategic organizational goals at all levels of the organization: micro, meso and macrosystem levels to achieve the ultimate quality and value a health care system is capable of offering.

Conduct Of Operations And Operational Discipline

Author: CCPS (Center for Chemical Process Safety)
Publisher: John Wiley & Sons
ISBN: 9781118029190
Size: 52.76 MB
Format: PDF, Kindle
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Process safety management (PSM) systems are only as effective as the day-to-day ability of the organization to rigorously execute system requirements correctly every time. The failure of just one person in completing a job task correctly just one time can unfortunately lead to serious injuries and potentially catastrophic incidents. In fact, the design, implementation, and daily execution of PSM systems are all dependent on workers at all levels in the organization doing their job tasks correctly every time. High levels of Operational Discipline, therefore, help ensure strong PSM performance and overall operational excellence. This book details management practices which help ensure rigor in executing process safety programs in order to prevent major accidents.

Just Culture

Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1317109899
Size: 59.29 MB
Format: PDF, Mobi
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A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the criminalization of human error. Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at 'accountability' in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous.

Sabiston Textbook Of Surgery E Book

Author: Courtney M. Townsend
Publisher: Elsevier Health Sciences
ISBN: 1455738085
Size: 64.44 MB
Format: PDF
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Sabiston Textbook of Surgery is your ultimate foundation for confident surgical decision making. Covering the very latest science and data affecting your treatment planning, this esteemed medical reference helps you make the most informed choices so you can ensure the best outcome for every patient. Consult it on the go with online access at expertconsult.com, and get regular updates on timely new findings and advances. Overcome tough challenges, manage unusual situations, and avoid complications with the most trusted advice in your field. Prepare for tests and exams with review questions and answers online. Keep up with the very latest developments concerning abdominal wall reconstruction, tumor immunology and immunotherapy, peripheral vascular disease, regenerative medicine, liver transplantation, kidney and pancreas transplantation, small bowel transplantation, the continually expanding role of minimally invasive and robotic surgery, and many other rapidly evolving areas. Weigh your options by reviewing the most recent outcomes data and references to the most current literature.

Understanding Policy Success

Author: Allan McConnell
Publisher: Palgrave MacMillan
ISBN:
Size: 37.74 MB
Format: PDF, ePub
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Success and failure are key to any consideration of public policy but there have been remarkably few attempts systematically to assess the various dimensions and complex nature of policy success. This important new text fills the gap by developing a systematic framework and offering an entirely new way of introducing students to policy analysis.