Safety I And Safety Ii

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Safety-I and Safety-II

Author : Erik Hollnagel
Publisher : CRC Press
Page : 167 pages
File Size : 48,6 Mb
Release : 2018-04-17
Category : Technology & Engineering
ISBN : 9781317059790

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Safety-I and Safety-II by Erik Hollnagel Pdf

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret

Safety-II in Practice

Author : Erik Hollnagel
Publisher : Taylor & Francis
Page : 130 pages
File Size : 50,9 Mb
Release : 2017-07-14
Category : Technology & Engineering
ISBN : 9781351780766

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Safety-II in Practice by Erik Hollnagel Pdf

Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance - an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering.

Resilient Health Care

Author : Erik Hollnagel,Jeffrey Braithwaite
Publisher : CRC Press
Page : 254 pages
File Size : 46,7 Mb
Release : 2019-07-23
Category : Medical
ISBN : 9781317065166

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Resilient Health Care by Erik Hollnagel,Jeffrey Braithwaite Pdf

Health care is everywhere under tremendous pressure with regard to efficiency, safety, and economic viability - to say nothing of having to meet various political agendas - and has responded by eagerly adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability. This has on the whole been met with limited success because health care as a non-trivial and multifaceted system differs significantly from most traditional industries. In order to allow health care systems to perform as expected and required, it is necessary to have concepts and methods that are able to cope with this complexity. Resilience engineering provides that capacity because its focus is on a system’s overall ability to sustain required operations under both expected and unexpected conditions rather than on individual features or qualities. Resilience engineering’s unique approach emphasises the usefulness of performance variability, and that successes and failures have the same aetiology. This book contains contributions from acknowledged international experts in health care, organisational studies and patient safety, as well as resilience engineering. Whereas current safety approaches primarily aim to reduce or eliminate the number of things that go wrong, Resilient Health Care aims to increase and improve the number of things that go right. Just as the WHO argues that health is more than the absence of illness, so does Resilient Health Care argue that safety is more than the absence of risk and accidents. This can be achieved by making use of the concrete experiences of resilience engineering, both conceptually (ways of thinking) and practically (ways of acting).

Safety Differently

Author : Sidney Dekker
Publisher : CRC Press
Page : 304 pages
File Size : 49,5 Mb
Release : 2014-06-23
Category : Technology & Engineering
ISBN : 9781482242003

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Safety Differently by Sidney Dekker Pdf

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 resu

The ETTO Principle: Efficiency-Thoroughness Trade-Off

Author : Professor Erik Hollnagel
Publisher : Ashgate Publishing, Ltd.
Page : 115 pages
File Size : 44,8 Mb
Release : 2012-10-01
Category : Transportation
ISBN : 9781409485995

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The ETTO Principle: Efficiency-Thoroughness Trade-Off by Professor Erik Hollnagel Pdf

Accident investigation and risk assessment have for decades focused on the human factor, particularly ‘human error’. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to understand why things go right and to amplify that. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.

Rethinking Patient Safety

Author : Suzette Woodward
Publisher : CRC Press
Page : 186 pages
File Size : 44,5 Mb
Release : 2017-03-27
Category : Medical
ISBN : 9781351651066

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Rethinking Patient Safety by Suzette Woodward Pdf

The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation. It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behavior and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story.

To Err Is Human

Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 312 pages
File Size : 51,7 Mb
Release : 2000-03-01
Category : Medical
ISBN : 9780309068376

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To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Engineering a Safer World

Author : Nancy G. Leveson
Publisher : MIT Press
Page : 555 pages
File Size : 48,9 Mb
Release : 2012-01-13
Category : Science
ISBN : 9780262297301

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Engineering a Safer World by Nancy G. Leveson Pdf

A new approach to safety, based on systems thinking, that is more effective, less costly, and easier to use than current techniques. Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and reliability engineering, created in a simpler, analog world, have changed very little over the years. In this groundbreaking book, Nancy Leveson proposes a new approach to safety—more suited to today's complex, sociotechnical, software-intensive world—based on modern systems thinking and systems theory. Revisiting and updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate, Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP), then shows how the new model can be used to create techniques for system safety engineering, including accident analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems. She applies the new techniques to real-world events including the friendly-fire loss of a U.S. Blackhawk helicopter in the first Gulf War; the Vioxx recall; the U.S. Navy SUBSAFE program; and the bacterial contamination of a public water supply in a Canadian town. Leveson's approach is relevant even beyond safety engineering, offering techniques for “reengineering” any large sociotechnical system to improve safety and manage risk.

Patient Safety and Quality Improvement in Healthcare

Author : Rahul K. Shah,Sandip A. Godambe
Publisher : Springer Nature
Page : 394 pages
File Size : 48,8 Mb
Release : 2020-12-15
Category : Medical
ISBN : 9783030558291

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Patient Safety and Quality Improvement in Healthcare by Rahul K. Shah,Sandip A. Godambe Pdf

This text uses a case-based approach to share knowledge and techniques on how to operationalize much of the theoretical underpinnings of hospital quality and safety. Written and edited by leaders in healthcare, education, and engineering, these 22 chapters provide insights as to where the field of improvement and safety science is with regards to the views and aspirations of healthcare advocates and patients. Each chapter also includes vignettes to further solidify the theoretical underpinnings and drive home learning. End of chapter commentary by the editors highlight important concepts and connections between various chapters in the text. Patient Safety and Quality Improvement in Healthcare: A Case-Based Approach presents a novel approach towards hospital safety and quality with the goal to help healthcare providers reach zero harm within their organizations.

Barriers and Accident Prevention

Author : Erik Hollnagel
Publisher : Routledge
Page : 213 pages
File Size : 50,5 Mb
Release : 2016-12-05
Category : Transportation
ISBN : 9781351955935

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Barriers and Accident Prevention by Erik Hollnagel Pdf

Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.

Advanced Safety Management Focusing on Z10 and Serious Injury Prevention

Author : Fred A. Manuele
Publisher : John Wiley & Sons
Page : 300 pages
File Size : 48,7 Mb
Release : 2011-09-20
Category : Technology & Engineering
ISBN : 9781118210161

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Advanced Safety Management Focusing on Z10 and Serious Injury Prevention by Fred A. Manuele Pdf

Learn how to improve the effectiveness of safety and health management systems by adopting ANSI Z10 provisions and avoid serious workplace injuries. This reference addresses specific provisions, including risk assessment methods and prioritization; applying a prescribed hierarchy of controls; implementing safety design reviews; and more. It also explains how to integrate best practices for the prevention of serious injuries in your workplace. See how implementing the ANSI Z10 standard can enhance your company’s productivity, cost efficiency, and quality.

Resilience Engineering

Author : David D. Woods
Publisher : CRC Press
Page : 328 pages
File Size : 44,5 Mb
Release : 2017-11-01
Category : Technology & Engineering
ISBN : 9781317065289

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Resilience Engineering by David D. Woods Pdf

For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive new book explores this groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering provides thought-provoking insights into system safety as an aggregate of its various components, subsystems, software, organizations, human behaviours, and the way in which they interact. The book provides an introduction to Resilience Engineering of systems, covering both the theoretical and practical aspects. It is written for those responsible for system safety on managerial or operational levels alike, including safety managers and engineers (line and maintenance), security experts, risk and safety consultants, human factors professionals and accident investigators.

Risk Science

Author : Terje Aven,Shital Thekdi
Publisher : Routledge
Page : 427 pages
File Size : 51,8 Mb
Release : 2021-09-12
Category : Technology & Engineering
ISBN : 9781000435030

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Risk Science by Terje Aven,Shital Thekdi Pdf

Risk science is becoming increasingly important as businesses, policymakers and public sector leaders are tasked with decision-making and investment using varying levels of knowledge and information. Risk Science: An Introduction explores the theory and practice of risk science, providing concepts and tools for understanding and acting under conditions of uncertainty. The chapters in this work cover the fundamental concepts, principles, approaches, methods and models for how to understand, assess, communicate, manage and govern risk. These topics are presented and examined in a way which details how they relate, for example, how to characterize and communicate risk with particular emphasis on reflecting uncertainties; how to distinguish risk perception and professional risk judgments; how to assess risk and guide decision-makers, especially for cases involving large uncertainties and value differences; and how to integrate risk assessment with resilience-based strategies. The text provides a variety of examples and case studies that relate to highly visible and relevant issues facing risk academics, practitioners and non-risk leaders who must make risk-related decisions. Presenting both the foundational and most recent advancements in the subject matter, this work particularly suits students of risk science courses at college and university level. The book also provides broader key reading for students and scholars in other domains, including business, engineering and public health.

Handbook of Safety Principles

Author : Niklas Möller,Sven Ove Hansson,Jan-Erik Holmberg,Carl Rollenhagen
Publisher : John Wiley & Sons
Page : 836 pages
File Size : 50,5 Mb
Release : 2018-02-21
Category : Business & Economics
ISBN : 9781118950692

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Handbook of Safety Principles by Niklas Möller,Sven Ove Hansson,Jan-Erik Holmberg,Carl Rollenhagen Pdf

Presents recent breakthroughs in the theory, methods, and applications of safety and risk analysis for safety engineers, risk analysts, and policy makers Safety principles are paramount to addressing structured handling of safety concerns in all technological systems. This handbook captures and discusses the multitude of safety principles in a practical and applicable manner. It is organized by five overarching categories of safety principles: Safety Reserves; Information and Control; Demonstrability; Optimization; and Organizational Principles and Practices. With a focus on the structured treatment of a large number of safety principles relevant to all related fields, each chapter defines the principle in question and discusses its application as well as how it relates to other principles and terms. This treatment includes the history, the underlying theory, and the limitations and criticism of the principle. Several chapters also problematize and critically discuss the very concept of a safety principle. The book treats issues such as: What are safety principles and what roles do they have? What kinds of safety principles are there? When, if ever, should rules and principles be disobeyed? How do safety principles relate to the law; what is the status of principles in different domains? The book also features: • Insights from leading international experts on safety and reliability • Real-world applications and case studies including systems usability, verification and validation, human reliability, and safety barriers • Different taxonomies for how safety principles are categorized • Breakthroughs in safety and risk science that can significantly change, improve, and inform important practical decisions • A structured treatment of safety principles relevant to numerous disciplines and application areas in industry and other sectors of society • Comprehensive and practical coverage of the multitude of safety principles including maintenance optimization, substitution, safety automation, risk communication, precautionary approaches, non-quantitative safety analysis, safety culture, and many others The Handbook of Safety Principles is an ideal reference and resource for professionals engaged in risk and safety analysis and research. This book is also appropriate as a graduate and PhD-level textbook for courses in risk and safety analysis, reliability, safety engineering, and risk management offered within mathematics, operations research, and engineering departments. NIKLAS MÖLLER, PhD, is Associate Professor at the Royal Institute of Technology in Sweden. The author of approximately 20 international journal articles, Dr. Möller's research interests include the philosophy of risk, metaethics, philosophy of science, and epistemology. SVEN OVE HANSSON, PhD, is Professor of Philosophy at the Royal Institute of Technology. He has authored over 300 articles in international journals and is a member of the Royal Swedish Academy of Engineering Sciences. Dr. Hansson is also a Topical Editor for the Wiley Encyclopedia of Operations Research and Management Science. JAN-ERIK HOLMBERG, PhD, is Senior Consultant at Risk Pilot AB and Adjunct Professor of Probabilistic Riskand Safety Analysis at the Royal Institute of Technology. Dr. Holmberg received his PhD in Applied Mathematics from Helsinki University of Technology in 1997. CARL ROLLENHAGEN, PhD, is Adjunct Professor of Risk and Safety at the Royal Institute of Technology. Dr. Rollenhagen has performed extensive research in the field of human factors and MTO (Man, Technology, and Organization) with a specific emphasis on safety culture and climate, event investigation methods, and organizational safety assessment.

Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies

Author : OECD,World Health Organization
Publisher : OECD Publishing
Page : 128 pages
File Size : 47,6 Mb
Release : 2019-10-17
Category : Electronic
ISBN : 9789264805903

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Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies by OECD,World Health Organization Pdf

This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.