The Field Guide To Understanding Human Error
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📒The Field Guide To Understanding Human Error ✍ Sidney Dekker
✏The Field Guide to Understanding Human Error Book Summary : 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 This old view of human error is increasingly outdated and will lead you nowhere.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.
📒The Field Guide To Understanding Human Error ✍ Professor Sidney Dekker
✏The Field Guide to Understanding Human Error Book Summary : This latest edition of The Field Guide to Understanding ‘Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization.
📒The Field Guide To Human Error Investigations ✍ Sidney Dekker
✏The Field Guide to Human Error Investigations Book Summary : This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.
📒On The Practice Of Safety ✍ Fred A. Manuele
✏On the Practice of Safety Book Summary : Explains how to implement the best safety practices and why they work Reviews from the Third Edition "An excellent piece of work." —Safety Health Practitioner (SHP) "A useful fountain of knowledge." —Quality World "This is a book to be read now for its educational value and also to be kept on the shelf for easy future reference." —Chemistry International The Fourth Edition of On the Practice of Safety makes it possible for readers to master all the core subjects and practices that today's safety professionals need to know in order to provide optimal protection for their organizations' property and personnel. Like the previous editions, each chapter is a self-contained unit, making it easy for readers to focus on select topics of interest. Thoroughly revised and updated, this Fourth Edition reflects the latest research and safety practice standards. For example, author Fred Manuele has revised the design chapters to reflect the recently adopted American National Standard on Prevention through Design. In addition, readers will find new chapters dedicated to: Management of change and pre-job planning Indirect-to-direct accident cost ratios Leading and lagging indicators Opportunities for safety professionals to apply lean concepts Role of safety professionals in implementing sustainability Financial management concepts and practices that safety professionals should know Many chapters are highly thought-provoking, questioning long-accepted concepts in the interest of advancing and improving the professional practice of safety. Acclaimed by both students and instructors, On the Practice of Safety is a core textbook for both undergraduate and graduate degree programs in safety. Safety professionals should also refer to the text in order to update and improve their safety skills and knowledge.
📒Lean Human Performance Improvement ✍ Jerry L. Harbour
✏Lean Human Performance Improvement Book Summary : As companies continue their efforts to improve work performance, they must ensure that their ongoing Lean activities include a healthy appreciation for, and recognition of, human performance. Ignoring the human component of work performance can be a recipe for unnecessary waste, inefficiency, and decreased productivity. Lean Human Performance Improvement presents a broad overview of human performance in the workplace. The author discusses his findings from a broad spectrum of human performance-related fields and diverse industrial sectors (gained by working in the field for over 30 years). Organized in three sections, this book covers understanding human performance, analyzing and improving work productivity, and analyzing and improving quality and safety. The author first develops a fundamental and basic understanding of human performance, then couples that understanding with learning how to analyze and improve human-related work productivity and quality and safety. He also discusses how knowledge and skills transfer from one work setting to another. Intended for Lean Six Sigma team members and human performance improvement practitioners, the book contains multiple examples from diverse work settings to explain key points. It also includes several major case studies. The goal of all examples and case studies is to develop a generic understanding that, in turn, can be successfully applied to any work setting.
📒Resilient Health Care Volume 2 ✍ Robert L. Wears
✏Resilient Health Care Volume 2 Book Summary : Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as ‘work-as-imagined’). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work breaks new ground by analysing everyday work situations in primary, secondary, and tertiary care to identify and describe the fundamental strategies that clinicians everywhere have developed and use with a fluency that belies the demands to be resolved and the dilemmas to be balanced. Because everyday clinical work is at the heart of resilience, it is essential to appreciate how it functions, and to understand its characteristics.
📒Value By Design ✍ Eugene C. Nelson
✏Value by Design Book Summary : Value by Design is a practical guide for real-world improvement in clinical microsystems. Clinical microsystem theory, as implemented by the Institute for Healthcare Improvement and health care organizations nationally and internationally, is the foundation of high-performing front line health care teams who achieve exceptional quality and value. These authors combine theory and principles to create a strategic framework and field-tested tools to assess and improve systems of care. Their approach links patients, families, health care professionals and strategic organizational goals at all levels of the organization: micro, meso and macrosystem levels to achieve the ultimate quality and value a health care system is capable of offering.
📒Conduct Of Operations And Operational Discipline ✍ CCPS (Center for Chemical Process Safety)
✏Conduct of Operations and Operational Discipline Book Summary : Process safety management (PSM) systems are only as effective as the day-to-day ability of the organization to rigorously execute system requirements correctly every time. The failure of just one person in completing a job task correctly just one time can unfortunately lead to serious injuries and potentially catastrophic incidents. In fact, the design, implementation, and daily execution of PSM systems are all dependent on workers at all levels in the organization doing their job tasks correctly every time. High levels of Operational Discipline, therefore, help ensure strong PSM performance and overall operational excellence. This book details management practices which help ensure rigor in executing process safety programs in order to prevent major accidents.
📒Cockpit Resource Management ✍ Earl L. Wiener
✏Cockpit Resource Management Book Summary : Cockpit Resource Management (CRM) has gained increased attention from the airline industry in recent years due to the growing number of accidents and near misses in airline traffic. This book, authored by the first generation of CRM experts, is the first comprehensive work on CRM. Cockpit Resource Management is a far-reaching discussion of crew coordination, communication, and resources from both within and without the cockpit. A valuable resource for commercialand military airline training curriculum, the book is also a valuable reference for business professionals who are interested in effective communication among interactive personnel. Key Features * Discusses international and cultural aspects of CRM * Examines the design and implementation of Line-Oriented Flight Training (LOFT) * Explains CRM, LOFT, and cockpit automation * Provides a case history of CRM training which improved flight safety for a major airline
📒Foundations Of Safety Science ✍ Sidney Dekker
✏Foundations of Safety Science Book Summary : How are today’s ‘hearts and minds’ programs linked to a late-19th century definition of human factors as people’s moral and mental deficits? What do Heinrich’s ‘unsafe acts’ from the 1930’s have in common with the Swiss cheese model of the early 1990’s? Why was the reinvention of human factors in the 1940’s such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? ‘Foundations of Safety Science’ covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today. Features Offers a comprehensive overview of the theoretical foundations of safety science Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use Uses an accessible style, using technical language where necessary Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches