This report presents a protocol for assessing team performance in terms of control based on cognitive systems engineering theories. The protocol changes the focus of team performance assessment from good and bad behaviours towards the team’s activity. By using Hollnagel’s contextual control model (COCOM) a protocol is developed so that team activity can be categorised into four control modes. Data

Effektiv kommunikation av riskbilden i länet mellan länsstyrelsen och allmänheten Examensarbetets slutsats är att länsstyrelsen borde samverka med kommunerna i en dialogbaserad kommunikation med allmänheten. Länsstyrelsen bör även försöka fylla de, i examensarbetet, identifierade kunskapsluckorna, vilka även kan utgöra framtida examensarbeten. Information av riskbilden till allmänheten är ett växThis master thesis deals with how an effective risk communication between the county administrative board and the public can be conducted. The master thesis starts with a summary of the current literature on the subject after which interviews were conducted with three individuals who work with these issues at the county administrative board in Kalmar and a number of questions were sent to a few mu

System-thinking and related systemic methods enhance traditional risk and hazard assessments and accident analysis, as well as system design. The Functional Resonance Analysis Method (FRAM) is a recently developed method for systemic analysis. FRAM facilitates descriptions of the functional relations among system elements. In case of large systems (e.g. several agents, multiple procedures, many te

Mountain communities are adapting their livelihoods to a complex combination of social, political and economic changes and associated risks. Despite recognition of adaption in response to multiple changes in sustainable livelihood and critical climate change literature, risks attributed to biophysical effects of climate change have increasingly assumed importance. Consequently, diversification is

The aim of the thesis was to study the information retrieval and seeking of an on-scene commander on the incident site. Also, to systematize the information to further improve the decision-making condition for all all of the commanding officers. By studying literature, analysing collected recorded material from helmet-mounted cameras and conducting interviews, the study has shown that commanders,

In this study, principles of Cognitive Systems Engineering are used to better understand the human–machine interaction manifesting in the use of anaesthesia alarms. The hypothesis is that the design of the machine incorporates built-in assumptions of the user that are discrepant with the anaesthesiologist's self-assessment, creating ‘user image mismatch’. Mismatch was interpreted by focusing on th

Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amou

Background: Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human – Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology.Methods: A bibliometric analysis was performed

In society, accidents happen on a daily basis. To investigate these accidents is part of preventing them from happening at all. The investigations are carried out by different reasons and with different focus as well as by varying methods and extent. This contributes to that the finding of causes of the event varies with the investigator as well as with what the purpose of the investigation is as

An increasingly heterogeneous demography in society demands for a shift of attitude towards crisis communication. With a population where one in five has got a foreign background it is important that governments and decision makers continuously evaluate the current crisis management plans, and take measures through updates where so is considered to be needed. This report aims to evaluate the curre

Resilience is becoming a prevalent agenda in safety research and organisational practice. In this study we examine how the peer-reviewed safety science literature (a) formulates the rationale behind the study of resilience; (b) constructs resilience as a scientific object; and (c) constructs and locates the resilient subject. The results suggest that resilience engineering scholars typically motiv

In this study, the duality of adaptive capacity in aviation safety is examined, where the need for resilience of frontline workers conflicts with the expectations and assumptions of upstream entities, leading to system brittleness. We explore three critical categories: responsibilization, the application of practical wisdom in navigating challenging situations, and the unrecognized sacrifices that

The objective presented in this thesis is to evaluate Fire Safety on Construction Products within the EU from the aspect of harmonisation. The variations in regulations between countries in the EU regarding Fire Safety may be an obstacle to the free trade of goods and services for Construction Products. The aim is to show to what degree the Building Codes are harmonised in respect to the use of Co

The field of child welfare could be considered one of the most complex social systems to work within. Whether punishing for errors or satisficing calls for accountability with firing employees and pointing to individuals as the root causes of bad outcomes, the current practice in child welfare is to utilize backward looking accountability. It is argued here that child welfare agencies would benefi

Recent high-visibility disasters have fueled public and political awareness of the importance of managing and mitigating their consequences effectively. In response, various countries have enacted legislation that demands the evaluation of emergency responses so that lessons for improvement can be learned. A series of field and experimental studies were conducted from 2005 to 2007 to assess the ab

There is widespread consensus that teamwork constitutes one of the key requirements in today’s multidisciplinary and highly complex system of delivering care. In recent years, increasing attention has been given to questions of how to define, teach, measure, and improve teamwork in healthcare. However, one cannot help but feel a certain disconnect between this ongoing trend in healthcare with an a

This report has arisen due to lack of fire protection in the upper secondary school Västerhöjdgymnasiet in Skövde, Sweden. The report analyzes demands on personal safety when evacuating the building based on applicable laws and regulations; no emphasis has been taken regarding economic losses. The goal is to achieve a satisfactory evacuation in case of fire. The chosen acceptance criterion is that

Over the past decade, flooding has been a great issue for several countries in Europe. With the movement of people and assets to flood prone areas, consequences due to flooding are increasing. Coping with this problem requires an effective response to flood risks. Therefore, this work has aimed to describe the emergency response to the 2013 flood incident in Suffolk, UK. This, in order to provide

Objective: The purpose of this study was to describe procedural changes in hospital incident investigations and show the consequences of these changes over time. Methods: A two-stage method was used. First component of the study was a content analysis of 87 incident investigations conducted 1995-2014 by the regulatory authority after adverse events in a Swedish university hospital. Second compone

Abstract in Undetermined In this study the distinction between complicated and complex is used to shed some light on compliance with best-practice guidelines. Data was gathered related to obstetric practice in labor wards and operating theatres at two Scandinavian hospitals, one of them being a university hospital, and in a training facility. The complexity of obstetrical intervention is analyzed