The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

Author: James Reason

Publisher: CRC Press

ISBN: 1351888110

Category: Technology & Engineering

Page: 310

View: 7782

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be ’bottled’ and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author’s focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
Posted in Technology & Engineering

The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

Author: J. T. Reason

Publisher: Ashgate Publishing, Ltd.

ISBN: 9780754674009

Category: Transportation

Page: 295

View: 3496

The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
Posted in Transportation

The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

Author: J. T. Reason

Publisher: Ashgate Publishing, Ltd.

ISBN: 9780754674023

Category: Technology & Engineering

Page: 295

View: 4719

The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
Posted in Technology & Engineering

A Life in Error

From Little Slips to Big Disasters

Author: Professor James Reason

Publisher: Ashgate Publishing, Ltd.

ISBN: 1472418417

Category: Political Science

Page: 150

View: 6845

This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. He presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. A Life in Error charts the development of his seminal and hugely influential work from its original focus on individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues.
Posted in Political Science

Managing the Risks of Organizational Accidents

Author: James Reason

Publisher: Routledge

ISBN: 1134855354

Category: Technology & Engineering

Page: 272

View: 1577

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.
Posted in Technology & Engineering

Managing Maintenance Error

A Practical Guide

Author: James Reason,Alan Hobbs

Publisher: CRC Press

ISBN: 1351920510

Category: Technology & Engineering

Page: 200

View: 6110

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer’s guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.
Posted in Technology & Engineering

Organizational Accidents Revisited

Author: James Reason

Publisher: CRC Press

ISBN: 1134806078

Category: Technology & Engineering

Page: 160

View: 7942

Managing the Risks of Organizational Accidents introduced the notion of an ’organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ’individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardized causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the ’raw data’ for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ’error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).
Posted in Technology & Engineering

Human Error

Author: James Reason

Publisher: Cambridge University Press

ISBN: 9780521314190

Category: Psychology

Page: 302

View: 3459

This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.
Posted in Psychology

The Field Guide to Understanding Human Error

Author: Sidney Dekker

Publisher: CRC Press

ISBN: 1351889753

Category: Technology & Engineering

Page: 252

View: 7748

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.
Posted in Technology & Engineering

What Went Wrong?

Case Studies of Process Plant Disasters

Author: Trevor Kletz

Publisher: Elsevier

ISBN: 9780080524238

Category: Technology & Engineering

Page: 408

View: 6584

Expert Trevor Kletz examines the causes and aftermaths of numerous plant disasters--almost every one of which could have been prevented. Case histories illustrate what went wrong, why it went wrong, and then guide you in how to circumvent similar tragedies. Learn from the mistakes of others. This invaluable and respected book examines the causes and aftermaths of numerous plant disasters - almost every one of which could have been prevented. Case histories illustrate what went wrong and why it went wrong, and then guide you in how to circumvent similar tragedies. * Learn from the mistakes of others with this important book! * Examines the causes and aftermaths of numerous plant disasters - most of which could have been prevented * Case histories illustrate what went wrong, why it went wrong, and then guide you in how to circumvent similar tragedies
Posted in Technology & Engineering

Beyond Aviation Human Factors

Safety in High Technology Systems

Author: Daniel E. Maurino,James Reason,Neil Johnston,Rob B. Lee

Publisher: Routledge

ISBN: 1351955691

Category: Transportation

Page: 181

View: 777

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction’s of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end?) involved in aviation operations, in addition to individual human performance (the sharp end?). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B
Posted in Transportation

Working Minds

A Practitioner's Guide to Cognitive Task Analysis

Author: Beth Crandall,Gary A. Klein,Robert R. Hoffman

Publisher: MIT Press

ISBN: 0262296942

Category: Psychology

Page: 352

View: 1782

Cognitive Task Analysis (CTA) helps researchers understand how cognitive skills and strategies make it possible for people to act effectively and get things done. CTA can yield information people need -- employers faced with personnel issues, market researchers who want to understand the thought processes of consumers, trainers and others who design instructional systems, health care professionals who want to apply lessons learned from errors and accidents, systems analysts developing user specifications, and many other professionals. CTA can show what makes the workplace work -- and what keeps it from working as well as it might.Working Minds is a true handbook, offering a set of tools for doing CTA: methods for collecting data about cognitive processes and events, analyzing them, and communicating them effectively. It covers both the "why" and the "how" of CTA methods, providing examples, guidance, and stories from the authors' own experiences as CTA practitioners. Because effective use of CTA depends on some conceptual grounding in cognitive theory and research -- on knowing what a cognitive perspective can offer -- the book also offers an overview of current research on cognition.The book provides detailed guidance for planning and carrying out CTA, with chapters on capturing knowledge and capturing the way people reason. It discusses studying cognition in real-world settings and the challenges of rapidly changing technology. And it describes key issues in applying CTA findings in a variety of fields. Working Minds makes the methodology of CTA accessible and the skills involved attainable.
Posted in Psychology

Crew Resource Management

Author: Earl L. Wiener,Barbara G. Kanki,Robert L. Helmreich

Publisher: Academic Press

ISBN: 9780080959009

Category: Technology & Engineering

Page: 625

View: 9825

The new edition of Crew Resource Management continues to focus on CRM in the cockpit, but also emphasizes that the concepts and training applications provide generic guidance and lessons learned for a wide variety of "crews" in the aviation system as well as in the complex and high-risk operations of many non-aviation settings. Long considered the "bible" in this field, much of the basic style and structure of the previous edition of Crew Resource Management is retained in the new edition. Textbooks are often heavily supplemented with or replaced entirely by course packs in advanced courses in the aviation field, as it is essential to provide students with cutting edge information from academic researchers, government agencies (FAA), pilot associations, and technology (Boeing, ALION). This edited textbook offers ideal coverage with first-hand information from each of these perspectives. Case examples, which are particularly important given the dangers inherent in real world aviation scenarios, are liberally supplied. An image collection and test bank make this the only text on the market with ancillary support. New material includes: international and cultural aspects of CRM; design and implementation of Line-Oriented Flight Training (LOFT); airline applications beyond the cockpit; spaceflight resource management; non-aviation applications; AQP; LOSA; and special issues pertaining to low-cost airline carriers. The second edition editors offer essential breath of experience in aviation human factors from multiple perspectives (academia, government, and private enterprise) and the contributors have all been chosen as experts in their fields who represent the diversity of the research of activities and organisational experience of CRM. The only CRM text on the market offering an up-to-date synthesis of primary source material New edition thoroughly updated and revised to include major new findings, complete with discussion of the international and cultural aspects of CRM, the design and implementation of LOFT Instructor website with testbank and image collection Liberal use of case examples
Posted in Technology & Engineering

Just Culture

Balancing Safety and Accountability

Author: Sidney Dekker

Publisher: Ashgate Publishing, Ltd.

ISBN: 1409440605

Category: Technology & Engineering

Page: 171

View: 9937

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.
Posted in Technology & Engineering

Safer Healthcare

Strategies for the Real World

Author: Charles Vincent,René Amalberti

Publisher: Springer

ISBN: 3319255592

Category: Medical

Page: 157

View: 8634

The authors of this book set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances. This work is supported by the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. The charity’s aim is a healthier population in the UK, supported by high quality health care that can be equitably accessed. The Foundation carries out policy analysis and makes grants to front-line teams to try ideas in practice and supports research into what works to make people’s lives healthier and improve the health care system, with a particular emphasis on how to make successful change happen. A key part of the work is to make links between the knowledge of those working to deliver health and health care with research evidence and analysis. The aspiration is to create a virtuous circle, using what works on the ground to inform effective policymaking and vice versa. Good health and health care are vital for a flourishing society. Through sharing what is known, collaboration and building people’s skills and knowledge, the Foundation aims to make a difference and contribute to a healthier population.
Posted in Medical

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, Second Edition

Author: Pascale Carayon

Publisher: CRC Press

ISBN: 1439830347

Category: Technology & Engineering

Page: 876

View: 3664

The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions, and applications and a greater range of domains such as medication safety, surgery, anesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
Posted in Technology & Engineering

Near Miss Reporting as a Safety Tool

Author: T.W. van der Schaaf,D.A. Lucas,A.R. Hale

Publisher: Butterworth-Heinemann

ISBN: 1483163628

Category: Business & Economics

Page: 160

View: 9441

Near Miss Reporting as a Safety Tool arises from a meeting of safety professionals, academicians, and consultants from Western-Europe and Canada held in Eindhoven, the Netherlands, in September 1989. The book deals with near-miss reporting in various systems, mostly in the context of errors and accidents. The book begins by discussing the effects of bad management decisions in the design phase and a framework that will describe or manage these near misses through reporting, description, analysis, interpretation, and suggestions. Seven modules that compose this framework, called the Near Miss Management System (NMMS), along with pertinent cases, are explained. The book notes that near misses are ignored because of technical myopia, action-oriented organizations, event-focused organizations, consequence driven, and variables in quality of reporting. The organizational and management aspects of the NMMS are then analyzed within the commonly accepted culture and experience of the company. The book also presents comparative application of near miss information systems covering a wide range of industrial and transport environment. Such presentation allows differences and similarities to come into view more easily. The text will prove valuable for safety professionals in the nuclear and chemical industry and in road, railway, and air traffic management. Professors and students in safety management will likewise appreciate this book.
Posted in Business & Economics

Resilient Health Care

Author: Professor Robert L Wears,Professor Erik Hollnagel,Professor Jeffrey Braithwaite

Publisher: Ashgate Publishing, Ltd.

ISBN: 1472469194

Category: Medical

Page: 296

View: 7389

Properly performing health care systems require concepts and methods that match their complexity. Resilience engineering provides that capability. It focuses on a system’s overall ability to sustain required operations under both expected and unexpected conditions rather than on individual features or qualities. This book contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. Whereas current safety approaches primarily aim to reduce the number of things that go wrong, Resilient Health Care aims to increase the number of things that go right.
Posted in Medical

Disasters

Learning the Lessons for a Safer World

Author: David Eves

Publisher: Routledge

ISBN: 1134957696

Category: Business & Economics

Page: 256

View: 6619

This is a reprint of ISBN 978-0-901357-46-5 Disasters: learning the lessons for a safer world is both a tribute to the victims of past safety failures and a warning against complacency and cutting corners today. It also recognises the achievements of health and safety professionals and others in learning the lessons of past mistakes. As Trevor Kletz has written, "Someone has paid the 'tuition fess'. There is no need for you to pay them again." Illustrated throughout in colour, the book looks at over 90 accidents, incidents and safety failures. Some, like Aberfan, Chernobyl and Hillsborough, are known simply by a single place name. Others have now faded from our collective consciousness but still have important lessons for us today, such as the early fires, explosions and mining disasters that paved the way for better safety management. Disasters: learning the lessons for a safer world offers: a description of events from 1800 to the present day a wide range of incidents, from explosions and fires to floods, pollution and human and animal ill health information on the background to each incident, what happened and the lessons that were learnt an exploration of the politics of disaster and risk reduction
Posted in Business & Economics

Statistics for Healthcare Professionals

An Introduction

Author: Ian Scott,Deborah Mazhindu

Publisher: SAGE

ISBN: 1446298027

Category: Medical

Page: 256

View: 6137

This book introduces you to the basic rules and principles of statistics and shows you how straightforward statistical tests can be performed and analysed in relation to healthcare. Key features of the text are: -Examples which show how statistics are used in the real world -Exercises to test your understanding and develop your proficiency -A glossary to remind you of key terms. -Additional online material including guides to using Microsoft Excel and SPSS and sample datasets.
Posted in Medical