Bakgrund Behandlingsriktlinjer omsätter vetenskaplig evidens till praktiska regler. De är en del av sjukvårdens säkerhetsåtgärder och syftar till att göra vården säker, enhetlig, möjliggör kvalitetskontroll och minskar sjukvårdskostnader. Men det är också viktigt att inte förväxla skapande eller hantering av dokument med att hantera faktisk säkerhet. Ett strikt fokus på följsamhet till regler kan Background: Clinical practice guidelines (CPGs) translate scientific knowledge into practical rules. They aim to improve safety, ensure consistency, enable quality control, and mitigate rising healthcare costs. CPGs and other written instructions are often the target or result of safety interventions in healthcare, but it is important to avoid the trap of managing documents rather than actual safe

Bridging the gap between understanding work-as-imagined and work-as-done in the perioperative work context represents an important aim of cognitive systems engineering research. Researching this context using a joint cognitive systems theoretical approach can reveal patterns of adaptation that have important implications for system design. Traditional research approaches by non-domain investigator

A suicide is a tragedy not only for family and relatives of the victim but also for the railway operator’s personnel and other witnesses. The aim of this report is to reduce the rate of suicides in the railway system by means of showing that society gains from measures that reduce the risk of suicides and fatal accidents. This is possible with a risk analysis that accounts for input uncertainties

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

The notion of patient safety entails protecting patients from preventable harm. This thesis presents suggestions on how the healthcare system, notably psychiatric healthcare, can understand and analyse patient safety risk as an emergent property of everyday interactions and relations. This view has itsconceptual roots in complexity theory.The overall aim is to understand patient safety risk as an

Recent accidents such as the Macondo blowout actualize the issue of offshore safety. Accidents do occur in spite of actions taken to prevent them from happening. The energy-barrier philosophy is the governing principle within the Norwegian offshore industry. The paradox with that philosophy is that the construction of additional barriers may increase complexity within the system. Risk may be seen

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

Analyzes of the terrorist attack on Drottninggatan have begun to be published. The risk is now that the debate will be governed by the logic of hindsight, that politicians and the media will be on the stands, pointing out mistakes and demand responsibility. Such a climate jeopardizes in the long run the development of our ability to prevent terrorist attacks, write four security researchers.

Improving teamwork has become a major safety goal for healthcare organizations. Audit tools currently available are useful, but they remain inadequate because they are reactive and fail to provide context for “the interaction between people and the operational context (i.e., organizational, regulatory and environmental factors) within which people discharge their operational duties” (Maurino, 2005

The Aviation industry is ultra-safe. Rules and procedures have been attributed as a contributory factor for attaining this high level of safety. The complexity of the aviation system has risen dramatically in the last few decades due to the development and introduction of modern aircraft and on-board technological innovations. Every day pilots encounter situations they did not expect. During those

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

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

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

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, 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

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

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

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

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