just culture balancing safety and accountability

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Just Culture

Author : Sidney Dekker
ISBN : 9781409440604
Genre : Technology & Engineering
File Size : 70. 79 MB
Format : PDF, Kindle
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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
ISBN : 9781439852262
Genre : Technology & Engineering
File Size : 33. 59 MB
Format : PDF, Mobi
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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
ISBN : 9781351889759
Genre : Technology & Engineering
File Size : 51. 90 MB
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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
ISBN : 9781134855353
Genre : Technology & Engineering
File Size : 32. 35 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.

Behind Human Error

Author : Dr Leila Johannesen
ISBN : 9781409486381
Genre : Health & Fitness
File Size : 24. 4 MB
Format : PDF, Mobi
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Human error is so often cited as a cause of accidents. There is perception of a 'human error problem'. Solutions are thought to lie in changing the people or their role. The label 'human error', however, is prejudicial and hides more than it reveals about how a system malfunctions. This book takes you behind the label. It explains how human error results from social and psychological judgments by the system's stakeholders that focus only on one facet of a set of interacting contributors.

Second Victim

Author : Sidney Dekker
ISBN : 9781466583412
Genre : Medical
File Size : 64. 21 MB
Format : PDF, Docs
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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 At The Sharp End

Author : Rhona Flin
ISBN : 9781317059943
Genre : Technology & Engineering
File Size : 22. 46 MB
Format : PDF, ePub, Mobi
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Many 21st century operations are characterised by teams of workers dealing with significant risks and complex technology, in competitive, commercially-driven environments. Informed managers in such sectors have realised the necessity of understanding the human dimension to their operations if they hope to improve production and safety performance. While organisational safety culture is a key determinant of workplace safety, it is also essential to focus on the non-technical skills of the system operators based at the 'sharp end' of the organisation. These skills are the cognitive and social skills required for efficient and safe operations, often termed Crew Resource Management (CRM) skills. In industries such as civil aviation, it has long been appreciated that the majority of accidents could have been prevented if better non-technical skills had been demonstrated by personnel operating and maintaining the system. As a result, the aviation industry has pioneered the development of CRM training. Many other organisations are now introducing non-technical skills training, most notably within the healthcare sector. Safety at the Sharp End is a general guide to the theory and practice of non-technical skills for safety. It covers the identification, training and evaluation of non-technical skills and has been written for use by individuals who are studying or training these skills on CRM and other safety or human factors courses. The material is also suitable for undergraduate and post-experience students studying human factors or industrial safety programmes.

Drift Into Failure

Author : Sidney Dekker
ISBN : 9781351942911
Genre : Technology & Engineering
File Size : 66. 63 MB
Format : PDF, Mobi
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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.

Influencing The Quality Risk And Safety Movement In Healthcare

Author : Kim Sears
ISBN : 9781317116929
Genre : Technology & Engineering
File Size : 44. 82 MB
Format : PDF, ePub
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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.

Accountability The Key To Driving A High Performance Culture

Author : Greg Bustin
ISBN : 9780071831383
Genre : Business & Economics
File Size : 27. 8 MB
Format : PDF
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Best practices for using accountability, trust, and purpose to turn your long-term vision into reality Accountability explains why the “carrot-and-stick” approach doesn’t work—and describes how to build and sustain a culture based on shared beliefs, positive action, and internal leadership development. The author’s conclusions are based on data resulting from his work with more than 3,000 executives worldwide, plus exclusive interviews with Fortune's Most Admired Companies and Best Places to Work. Greg Bustin has written a monthly bulletin about leadership and accountability that goes to more than 4,000 managers/executives. He speaks about 50 times per year in the U.S., Canada, and the UK and is one of the top-rated Vistage speakers. He also gives workshops and webinars on planning, execution, and accountability to business owners and leaders in the U.S. and Canada.

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