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Content ArticleThis report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes.
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Content ArticleThis paper addresses the fundamental discipline theoretic question of whether situation awareness is a phenomenon best described by psychology, engineering or systems ergonomics. Each of these disciplines places a different emphasis on the notion of what situation awareness is and how it manifests itself. Each of the perspectives is presented and compared with reference to studies in aviation and other domains.
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Content ArticleLearning vicariously from the experiences of others at work, such as those working on different teams or projects, has long been recognised as a driver of collective performance in organisations. Yet as work becomes more ambiguous and less observable in knowledge-intensive organisations, previously identified vicarious learning strategies, including direct observation and formal knowledge transfer, become less feasible. Drawing on ethnographic observations and interviews with flight nurse crews in an air medical transport program, Chris Myers inductively build a model of how storytelling can serve as a valuable tool for vicarious learning. He explores a multistage process of triggering, telling, and transforming stories as a means by which flight nurses convert the raw experience of other crews’ patient transports into prospective knowledge and expanded repertoires of responses for potential future challenges. Further, he highlights how this storytelling process is situated within the transport programme’s broader structures and practices, which serve to enable flight nurses’ storytelling and to scale the lessons of their stories throughout the entire programme. He discusses the implications of these insights for the study of storytelling as a learning tool in organizations, as well as for revamping the field’s understanding of vicarious learning in knowledge-intensive work settings.
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Content ArticlePatients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organisations and healthcare, and the extent of patient safety incidents is still unclear. This study in the Journal of Patient Safety is based on in-depth interviews with eight experienced Norwegian HEMS physicians from four different bases from February to July 2020. The study aimed to explore the physicians’ experience with incident reporting and their perceived areas of risk in HEMS. The authors concluded that sparse, informal and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. A focus on organisational factors and system responsibility is needed to further improve patient safety in HEMS, alongside research on environmental and contextual factors.
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Content ArticleJudy Walker looks at the ways in which team learning can contribute to safety in healthcare using tools such as After Action Review (AAR). She explores research highlighted in Amy Edmondson's new book The Right Kind of Wrong that demonstrates the impact on certain safety indicators of flight crews building a team culture through working together consistently. Judy suggests that gaining insights about co-workers through proximity accelerates the process of learning for teams.
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Content Article
Designing in risk: Measuring safety part 3
NMacLeod posted an article in Improving patient safety
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The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management. Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.- Posted
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Content ArticleThe helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured. The investigation carried out by the Air Accidents Investigation Branch identified the following causal factors: The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash. Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.
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Content Article
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. -
Content Article
Can you measure safety? Part 1
NMacLeod posted an article in Improving patient safety
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.- Posted
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News ArticlePeople concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes? That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps. But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry. The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies. A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public. Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences. Read full story Source: CNN, 30 May 2023 Related reading on the hub: Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative
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Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue is on the theme of Handling Surprises: Tales of the Unexpected. You will find a diverse selection of articles from frontline staff, senior managers, and specialists in operations, human factors, safety, and resilience engineering in the context of aviation, healthcare, maritime and web operations. The articles reflect surprise handling by individuals, teams and organisations from the perspectives of personal experience, theory, research and training.
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Content ArticleAdam Tasker spent over a decade in the Royal Navy before starting medical training at the University of Warwick. In this article for BMJ Leader, he reflects on a near miss incident that he was involved in while working as a Helicopter Warfare Officer, examining his attitudes and those of his colleagues, and the practices and behaviours of the squadron’s leaders. He compares his experience in the Royal Navy to that of his experience as a medical student, and identifies lessons that are relevant to medical training, professional expectations and the management of clinical incidents. These lessons aim to support the implementation of a Just Culture within the NHS.
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A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated. Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research. -
Content ArticleSometimes after an incident, a system-wide change is implemented that makes work more difficult and creates new problems. This story from aviation is one such example, which contains useful lessons for responding to rare events. Steven Shorrock recounts the tale.
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Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
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Content Article
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Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.- Posted
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Laura and Suzy talk to us about the importance of embedding human factors in the design of healthcare systems and tools, the importance of equipping staff to think about system safety, and their work to establish a nationwide conversation about the impact of fatigue. -
Content ArticleFatigue is increasingly considered as one of the most significant hazards to aviation safety and other safety-critical industries. Both the academic community and industry have focused on understanding the phenomenon of fatigue and the factors that contribute to it in order to prevent it, but also to mitigate its possible consequences. As a result, procedures and regulations have been developed for operators to comply with and there is now a requirement for operators to demonstrate that they are actively managing fatigue. The aim of this white paper by Clockwork Research is to provide safety practitioners with a better understanding of the process of investigating fatigue.
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Content ArticleThe theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
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Content ArticleThis issue of Hindsight concerns ‘the new reality’ that we are facing. It includes a wide variety of articles from frontline staff and specialists in safety, human factors, psychology, aeromedical, and human and organisational performance in aviation. There are also insights from healthcare, shipping, rail, community development and psychotherapy.
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Content ArticleThis issue of Hindsight is on the theme of digitalisation and human performance. It includes a wide variety of articles from frontline staff and specialists in technology, change, safety, human factors, and human and organisational performance in aviation. There are also insights from healthcare and pharmaceutical manufacturing. The articles reflect the possibilities for digitalisation and human performance, and the challenges for individuals, teams, organisations, regulators, industries, and societies.
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Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content Article
Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this. -
Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content ArticleHigh Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. The authors of this study introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. The authors explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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