In public safety oversight authorities are traditionally assumed responsible of safeguarding operation and promoting safety by defining prescriptions and observing that they are complied with. Regulated entities on their side are assumed responsibility for complying. While this compliance-based approach has contributed to current levels of safety, it is increasingly debated that it has limitatio

Recent contributions to the field of Resilience Engineering (RE) have added to the continuous development of new concepts and methodologies to improve resilience at different organisational levels. Part of these contributions has focused on training for adaptive capacity of individuals and teams to cope with changes and disturbances of work, since literature recognise that working tasks (at least

We pursued the following three interconnected points: (1) there are unexplored opportunities for resilience scholars from different disciplines to cross-inspire and inform, (2) a systems perspective may enhance understanding of human resilience in health and social settings, and (3) resilience is often considered to be fractal, i.e., a phenomenon with recognizable or recurring features at a variet

Growing concerns regarding the vulnerability of communities to natural disasters and climate-related hazards and risks have caused attention to be increasingly directed towards adaptation and resilience as important policy prescriptions. These two concepts are commonly becoming normative when used in this context and seen as intrinsically linked to each other, i.e. adaptation leads to resilience a

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

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

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

Background This study identifies a promising, new focus for the crisis management research in the health care domain. After reviewing the literature on health care crisis management, there seems to be a knowledge-gap regarding organisational change and adaption, especially when health care situations goes from normal, to non-normal, to pathological and further into a state of emergency or crisis.

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.

Throughout time, communities have adapted to changes in their environment and, in doing so, have addressed risksthat threaten the things they value. The need to adapt is considered more urgent now than ever, notably given thecurrent focus on climate risk. Typically, adaptation is presented as a solution to reduce such risks. This is particularlythe case for Landlocked Developing Countries and Smal

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

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

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

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

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