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

In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types o

Occupational health and safety management systems are widely used as a systematic approach to managing occupational health and safety in organizations. One important element of which is the development of Standard Operating Procedures to ensure uniform written safety procedures throughout the organization. Such procedures are sometimes restrictive and inadequate to deal with the dynamic and changi

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, with an associated bia

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

Syftet med rapporten är att ur ett kritiskt perspektiv analysera statens konstruktion av den lilla kommunens krishanteringsförmåga, samt tydliggöra de eventuella brister, svagheter eller oklarheter som identifieras. De frågeställningar som specifikt har önskat besvaras är om Myndigheten för samhällsskydd projektgrupp har beaktat det kommunala självstyret vid framtagandet av ASH, om ett kommunalför

Context This research looks at managing uncertainty and recovery processes following failure of a sociotechnical system. The provision of Air Traffic Services (ATS) is an essential service that must continue to function supporting at a minimum; medical flights, search and rescue operations, humanitarian aid, State and military flights (as demonstrated during the recent global pandemic). Purpose Th

This paper aims at determine how a new accident investigation method should be designed in order to bring a more holistic view of the system of a manufacturing industry. This is especially important for an organization like Xylem, since complex systems needs methods that can handle the complexity. In order to do this the author has performed interviews and a study of accident reports from a compan

The Forest Service has declared its intention of becoming a learning organization. As a means to that end, the Forest Service has borrowed and adapted the staff ride concept from the military. This paper describes the staff ride product and compares it to what scientific research tells us about the nature of learning. Focus group sessions were conducted to ascertain the strengths and weaknesses of

Deepwater drilling operates high hazardous and complex systems. Technological and operational complexities, harsh environmental conditions, geological uncertainties, and high-pressure flammable fluids are some of the critical factors that pose clear threats towards safe operations and may result in high consequence events, as the Macondo blowout in 2010. The continuous demand for oil and gas push

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

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

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

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