ORCID Profile
0000-0002-9141-3374
Current Organisation
Griffith University
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Other Psychology and Cognitive Sciences | Clinical Nursing: Secondary (Acute Care) | Psychology and Cognitive Sciences not elsewhere classified | Computer-Human Interaction
Health and Support Services not elsewhere classified | Expanding Knowledge in Psychology and Cognitive Sciences |
Publisher: Springer Science and Business Media LLC
Date: 15-06-2012
Publisher: Informa UK Limited
Date: 03-2013
DOI: 10.1080/00140139.2012.718799
Abstract: Technology offers a promising route to a sustainable future, and ergonomics can serve a vital role. The argument of this article is that the lasting success of sustainability initiatives in ergonomics hinges on an examination of ergonomics' own epistemology and ethics. The epistemology of ergonomics is fundamentally empiricist and positivist. This places practical constraints on its ability to address important issues such as sustainability, emergence and complexity. The implicit ethical position of ergonomics is one of neutrality, and its positivist epistemology generally puts value-laden questions outside the parameters of what it sees as scientific practice. We argue, by contrast, that a discipline that deals with both technology and human beings cannot avoid engaging with questions of complexity and emergence and seeking innovative ways of addressing these issues. Ergonomics has largely modelled its research on a reductive science, studying parts and problems to fix. In sustainability efforts, this can lead to mere local adaptations with a negative effect on global sustainability. Ergonomics must consider quality of life globally, appreciating complexity and emergent effects of local relationships.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2015
Publisher: Elsevier BV
Date: 07-2012
Publisher: Informa UK Limited
Date: 29-02-2016
Publisher: Institute of Electrical and Electronics Engineers (IEEE)
Date: 03-2003
Publisher: Elsevier BV
Date: 2024
Publisher: Informa UK Limited
Date: 03-2014
Publisher: Wiley
Date: 23-07-2014
Publisher: Wiley
Date: 28-06-2008
Publisher: Emerald
Date: 10-2003
DOI: 10.1108/09653560310493123
Abstract: One of the most obvious problems for those involved with disaster relief work is coordination with other teams in the field, with headquarters, with the mother organization in the home country and having to deal with unanticipated situations. The central dilemma appears to be this: disaster relief workers either have the knowledge to know what to do or the authority to do it. Seldom, however, are the local knowledge of what to do and the authority to do it located in the same person. This mismatch creates instability which generates pressure for change. Such change occurs through what we describe as “renegotiations of authority” – where people or teams who are not officially in charge take authority to act, because they know what to do and how urgent it is to do it. This paper presents the concept of renegotiations of authority through cycles of breaking down qualitative data obtained from disaster workers from multiple organizations and countries.
Publisher: Springer Science and Business Media LLC
Date: 15-01-2012
Publisher: Informa UK Limited
Date: 02-01-2016
DOI: 10.1080/10803548.2015.1112104
Abstract: Many industries are confronted by plateauing safety performance as measured by the absence of negative events--particularly lower-consequence incidents or injuries. At the same time, these industries are sometimes surprised by large fatal accidents that seem to have no connection with their understanding of the risks they faced or with how they were measuring safety. This article reviews the safety literature to examine how both these surprises and the asymptote are linked to the very structures and practices organizations have in place to manage safety. The article finds that safety practices associated with compliance, control and quantification could be partly responsible. These can create a sense of invulnerability through safety performance close to zero organizational resources can get deflected into unproductive or counterproductive initiatives obsolete practices for keeping human performance within a pre-specified bandwidth are sustained and accountability relationships can encourage suppression of the 'bad news' necessary to learn and improve.
Publisher: Massachusetts Medical Society
Date: 21-01-2010
DOI: 10.1056/NEJMC0910312
Publisher: Cambridge University Press (CUP)
Date: 2002
DOI: 10.1017/S0373463301001588
Abstract: In this paper, we discuss the grounding of the Royal Majesty , reconstructed from the perspective of the crew. The aim is particularly to understand the role of automation in shaping crew assessments and actions. Automation is often introduced because of quantitative promises that: it will reduce human error reduce workload and increase efficiency. But as demonstrated by the Royal Majesty , as well as by numerous research results, automation has qualitative consequences for human work and safety, and does not simply replace human work with machine work. Automation changes the task it was meant to support it creates new error pathways, shifts consequences of error further into the future and delays opportunities for error detection and recovery. By going through the sequence of events that preceded the grounding of the Royal Majesty , we highlight the role that automation plays in the success and failure of navigation today. We then point to future directions on how to make automated systems into better team players.
Publisher: Wiley
Date: 18-12-2009
DOI: 10.1002/PRS.10286
Publisher: Elsevier
Date: 2004
Publisher: Informa UK Limited
Date: 03-2013
Publisher: Springer Science and Business Media LLC
Date: 04-06-2014
Publisher: Elsevier BV
Date: 05-2012
DOI: 10.1016/J.APERGO.2011.07.003
Abstract: Complexity is a defining characteristic of healthcare, and ergonomic interventions in clinical practice need to take into account aspects vital for the success or failure of new technology. The introduction of new monitoring technology, for ex le, creates many ripple effects through clinical relationships and agents' cross-adaptations. This paper uses the signal detection paradigm to account for a case in which multiple clinical decision makers, across power hierarchies and gender gaps, manipulate each others' sensitivities to evidence and decision criteria. These are possible to analyze and predict with an applied ergonomics that is sensitive to the social complexities of the workplace, including power, gender, hierarchy and fuzzy system boundaries.
Publisher: Informa UK Limited
Date: 14-10-2015
Publisher: Springer Science and Business Media LLC
Date: 19-02-2009
Publisher: Elsevier BV
Date: 05-2009
DOI: 10.1016/J.APERGO.2008.10.005
Abstract: The Human Error Template (HET) is a recently developed methodology for predicting design-induced pilot error. This article describes a validation study undertaken to compare the performance of HET against three contemporary Human Error Identification (HEI) approaches when used to predict pilot errors for an approach and landing task and also to compare analyst error predictions to an approach to enhancing error prediction sensitivity: the multiple analysts and methods approach, whereby multiple analyst predictions using a range of HEI techniques are pooled. The findings indicate that, of the four methodologies used in isolation, analysts using the HET methodology offered the most accurate error predictions, and also that the multiple analysts and methods approach was more successful overall in terms of error prediction sensitivity than the three other methods but not the HET approach. The results suggest that when predicting design-induced error, it is appropriate to use a toolkit of different HEI approaches and multiple analysts in order to heighten error prediction sensitivity.
Publisher: Elsevier BV
Date: 07-2011
Publisher: Springer Science and Business Media LLC
Date: 25-01-2015
Publisher: Cambridge University Press (CUP)
Date: 2007
DOI: 10.1111/J.1748-720X.2007.00168.X
Abstract: We say that celebrated accidents shape public perception of safety and risk in health care. Take the so-called celebrated story of the three Colorado nurses who, by administering bezathine penicillin intravenously, caused the death of a neonate. The nurses were charged with criminal negligence, with one pleading guilty to a reduced charge and another fighting the charge and eventually being exonerated. “Celebrated” accidents (i.e., celebrated in the media and, accordingly, popular imagination, lified momentarily by the media as it may get ferried along from courtroom to courtroom) seem to follow a predictable script and cast participants in recognizable roles. They present heroes (e.g., a care provider who tried to save the patient despite the odds and errors of others), survivors, and victims. And, of course, they put villains, or anti-heroes, center stage – the chief protagonists of a fatal plot.
Publisher: Informa UK Limited
Date: 03-07-2018
Publisher: Elsevier BV
Date: 10-2016
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.APERGO.2016.02.007
Abstract: Rational choice theory says that operators and others make decisions by systematically and consciously weighing all possible outcomes along all relevant criteria. This paper first traces the long historical arm of rational choice thinking in the West to Judeo-Christian thinking, Calvin and Weber. It then presents a case study that illustrates the consequences of the ethic of rational choice and in idual responsibility. It subsequently examines and contextualizes Rasmussen's legacy of pushing back against the long historical arm of rational choice, showing that bad outcomes are not the result of human immoral choice, but the product of normal interactions between people and systems. If we don't understand why people did what they did, Rasmussen suggested, it is not because people behaved inexplicably, but because we took the wrong perspective.
Publisher: Springer Science and Business Media LLC
Date: 24-12-2012
Publisher: Informa UK Limited
Date: 03-1995
Publisher: Informa UK Limited
Date: 03-2000
DOI: 10.1207/STHF0201_8
Publisher: Elsevier BV
Date: 11-2010
Publisher: Elsevier BV
Date: 12-2014
Publisher: Informa UK Limited
Date: 03-2000
DOI: 10.1207/STHF0201_7
Publisher: Wiley
Date: 2008
DOI: 10.1002/9780470087923.HHS298
Abstract: Security and safety share fundamentally important features as operational activities with the goal to protect people, property, and the smooth economical functioning of organizations and society. In safety‐critical industries, safety is seen as the positive outcome of management of problems and trade‐offs that are rooted in systems' complexity, goal interaction, and resource limitations. This perspective has led safety research to shift focus and go beyond in idual acts and move to systematic aspects of human, technological, and organizational performance. It involves dealing with problems connected to regulations and standardized procedures, technology and automation, and efforts to understand the impact of communication, group dynamics, leadership, and culture on safety. In spite of distinct differences in the nature of threats (intentional/unintentional), there are many areas (use of standardized procedures, human factors training, and modeling for increased understanding of adverse events) where knowledge and experiences from safety operations can fruitfully spill over to security. To establish cooperation between these two fields, for ex le on regulatory and procedural development, training and simulation, as well as operational evaluation, would be to produce synergies not yet known today.
Publisher: Springer Science and Business Media LLC
Date: 08-06-2013
Publisher: Elsevier BV
Date: 10-2011
Publisher: Elsevier BV
Date: 06-2001
DOI: 10.1016/S0003-6870(00)00066-1
Abstract: Recent air traffic control regulations mandate the installation of computer-based flight management systems in airliners across Europe. Integrating and certifying add-on cockpit systems is a long and costly process, which in its current form cannot meaningfully address ergonomics aspects. Two levels of problems occur: add-on systems carry many "classic" HCI failures, which could easily be addressed with modified certification requirements. Further, adding new technology changes practice, creates new skill and knowledge demands and produces new forms of error, which are more difficult to assess in advance. However, one innovative certification approach for add-on cockpit systems, based on the use of a representative population of user pilots, was found to be promising. This method minimizes the subjective bias of in idual pilots in addition to defining pass/fail criteria in an operational environment.
Publisher: BMJ
Date: 09-12-2016
Publisher: Elsevier BV
Date: 06-2016
Publisher: Informa UK Limited
Date: 08-2011
DOI: 10.1080/00140139.2011.592607
Abstract: This paper raises the issue of ergonomics' role in giving primacy to fully rational in idual human actors in the creation of system failure, despite its commitment to see action as constrained by design and operational features of work. Reflecting on recent contributions to the journal, ergonomics' dilemma is considered against Enlightenment assumptions about in idual human reason as the route to truth and goodness and its critics in continental philosophy. There is a pervasive, unstated pact here. What ergonomics chooses to call certain things (violations, errors, non-compliance, situation awareness) not only simultaneously affirms and denies full rationality on part of the people it studies, it also coincides with what the West sees as scientific, true and instrumental. Thus, ergonomics research legitimates its findings in terms it is expected to explain itself in. But by doing so, it reproduces the very social order it set out to repudiate. Statement of Relevance: Ergonomics' choice of words (violations, errors, non-compliance) at once affirms and denies full rationality on part of the people it studies, reproducing the very social order it is meant to question and change.
Publisher: Elsevier
Date: 2010
Publisher: Elsevier BV
Date: 02-2011
Publisher: Informa UK Limited
Date: 12-2004
DOI: 10.1080/00140130412331290853
Abstract: Ergonomics design is about the creation of future work. So how can ergonomics research support and inform design if its findings are cast in a language oriented towards current work derived from field observations or laboratory settings? In this paper we assess instances of three different strands (experimental, ethnomethodological, and surveys) of ergonomics research on paper flight strips in air traffic control, for how they analytically confront future work and how they make the findings relevant or credible with respect to future work. How these justifications come about, or how valid (or well argued for) they are, is rarely considered in the ergonomics literature. All three strands appear to rely on rhetoric and argument as well as method and analysis, to justify findings in terms of their future applicability. Closing the gap between research results and future work is an important aim of the ergonomic enterprise. Better understanding of the processes necessary to bridge this gap may be critical for progress in ergonomics research and for the use of its findings in actual design processes.
Publisher: IGI Global
Date: 2013
DOI: 10.4018/978-1-4666-2509-9.CH011
Abstract: The Gaussian copula, an equation first published by David Li in 2000, was a beautiful thing—in isolation. Its intention was to price collaterized debt obligations, and work out whether they were moving in the same direction. The copula was an enabler of mortgaging the most hopeless of homeowner prospects. Millions of securities could be traded on the back of a single number (a security is something that shows ownership, or right of ownership of stocks or bonds, or the right to ownership connected with derivatives that get their value from some underlying asset). As more and more webs of interactions and relationships and interdependencies and feedback loops started growing around it, however, it became part of a complex system. The copula became the trigger of a recession that swelled the number of homeless families in the US by 30% inside of two years (Associated Press, 2010). It ended up bringing global lending to a virtual standstill, triggering a worldwide financial crisis and a deep recession. How did a once good idea like this drift into failure, and how can such a risk of collapse be managed? That is what this chapter is about.
Publisher: Informa UK Limited
Date: 05-2003
Publisher: Elsevier BV
Date: 12-2014
Publisher: SAGE Publications
Date: 04-2007
Abstract: Objective: This paper analyzes some of the problems with error counting as well as the difficulty of proposing viable alternatives. Background: Counting and tabulating negatives (e.g., errors) are currently popular ways to measure and help improve safety in a variety of domains. They uphold an illusion of rationality and control but may offer neither real insight nor productive routes for improving safety. Method: The paper conducts a critical analysis of assumptions underlying error counting in human factors. Results: Error counting is a form of structural analysis that focuses on (supposed) causes and consequences it defines risk and safety instrumentally in terms of minimizing negatives and their measurable effects. In this way, physicians can be proven to be 7500 times less safe than gun owners, as they are responsible for many more accidental deaths. Conclusion: The appeal of error counting may lie in a naive realism that can enchant researchers and practitioners alike. Supporting facts will continue to be found by those looking for errors through increasingly refined methods. Application: The paper outlines a different approach to understanding safety in complex systems that is more socially and politically oriented and that places emphasis on interpretation and social construction rather than on putatively objective structural features.
Publisher: Elsevier BV
Date: 10-2002
DOI: 10.1016/S0022-4375(02)00032-4
Abstract: How can human contributions to accidents be reconstructed? Investigators can easily take the position a of retrospective outsider, looking back on a sequence of events that seems to lead to an inevitable outcome, and pointing out where people went wrong. This does not explain much, however, and may not help prevent recurrence. This paper examines how investigators can reconstruct the role that people contribute to accidents in light of what has recently become known as the new view of human error. The commitment of the new view is to move controversial human assessments and actions back into the flow of events of which they were part and which helped bring them forth, to see why assessments and actions made sense to people at the time. The second half of the paper addresses one way in which investigators can begin to reconstruct people's unfolding mindsets. In an era where a large portion of accidents are attributed to human error, it is critical to understand why people did what they did, rather than judging them for not doing what we now know they should have done. This paper helps investigators avoid the traps of hindsight by presenting a method with which investigators can begin to see how people's actions and assessments actually made sense at the time.
Publisher: Informa UK Limited
Date: 10-2000
Publisher: Wiley
Date: 30-08-2007
DOI: 10.1111/J.1445-2197.2007.04253.X
Abstract: As stakeholders struggle to reconcile calls for accountability and pressures for increased patient safety, criminal prosecution of surgeons and other health-care workers for medical error seems to be on the rise. This paper examines whether legal systems can meaningfully draw a line between acceptable performance and negligence. By questioning essentialist assumptions behind 'crime' or 'negligence', this paper suggests that multiple overlapping and partially contradictory descriptions of the same act are always possible, and even necessary, to approximate the complexity of reality. Although none of these descriptions is inherently right or wrong, each description of the act (as negligence, or system failure, or pedagogical issue) has a fixed repertoire of responses and countermeasures appended to it, which enables certain courses of action while excluding others. Simply holding practitioners accountable (e.g. by putting them on trial) excludes any beneficial effects as it produces defensive posturing, obfuscation and excessive stress and leads to defensive medicine, silent reporting systems and interference with professional oversight. Calls for accountability are important, but accountability should be seen as bringing information about needed improvements to levels or groups that can do something about it, rather than deflecting resources into legal protection and limiting liability. We must avoid a future in which we have to turn increasingly to legal systems to wrong accountability out of practitioners because legal systems themselves have increasingly created a climate in which telling each other accounts openly is less and less possible.
Publisher: Informa UK Limited
Date: 2003
DOI: 10.1080/10803548.2003.11076564
Abstract: "Human error" is often cited as cause of occupational mishaps and industrial accidents. Human error, however, can also be seen as an effect (rather than the cause) of trouble deeper inside systems. The latter perspective is called the "new view" in ergonomics today. This paper details some of the antecedents and implications of the old and the new view, indicating that human error is a judgment made in hindsight, whereas actual performance makes sense to workers at the time. Support for the new view is drawn from recent research into accidents as emergent phenomena without clear "root causes " where deviance has become a generally accepted standard of normal operations and where organizations reveal "messy interiors" no matter whether they are predisposed to an accident or not.
Publisher: Elsevier BV
Date: 07-2014
Publisher: SAGE Publications
Date: 24-02-2015
Abstract: In providing reflections on 25 years of situation awareness (SA) research, particularly the ever-popular 1995 model of SA, our response is twofold. First, we ask whether the model’s grasp has exceeded its epistemological reach. By overlooking important insights from the second cognitive revolution as well as from other late-20th-century developments in (social) science, it might well do that. In fact, SA, in its 1995 model, is strongly committed to a 17th-century ontology that separates mind from matter and sees awareness as a correspondence or mirror of the world outside. This view seems to strongly reverberate today in a somewhat dogmatic stance of the 1995 model about the role that the world and cognitive artifacts play in constituting cognitive processes. Second, we suggest that after 25 years of SA, we might need to reflect on what SA as a scientific human factors object has brought us or the operators we once set out to support. This is not a trivial or academic question. We know of one operator who is in jail today because the prosecution was able to successfully argue for the dereliction of his duty to maintain SA. Without the human factors community supplying this object, he might still be in jail, but surely not under this charge.
Publisher: Springer Science and Business Media LLC
Date: 14-11-2022
DOI: 10.1007/S11948-022-00412-2
Abstract: Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator’s role in approving the Boeing 737MAX—a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to ‘speak up,’ then the ethical essence of engineering—skepticism, testing, checking, and questioning—has already failed.
Publisher: Springer Science and Business Media LLC
Date: 17-09-2011
Publisher: Elsevier BV
Date: 05-2003
Publisher: Elsevier BV
Date: 07-2022
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.AAP.2013.12.010
Abstract: The concept of culture is now widely used by those who conduct research on safety and work-related injury outcomes. We argue that as the term has been applied by an increasingly erse set of disciplines, its scope has broadened beyond how it was defined and intended for use by sociologists and anthropologists. As a result, this more inclusive concept has lost some of its precision and analytic power. We suggest that the utility of this "new" understanding of culture could be improved if researchers more clearly delineated the ideological - the socially constructed abstract systems of meaning, norms, beliefs and values (which we refer to as culture) - from concrete behaviors, social relations and other properties of workplaces (e.g., organizational structures) and of society itself. This may help researchers investigate how culture and social structures can affect safety and injury outcomes with increased analytic rigor. In addition, maintaining an analytical distinction between culture and other social factors can help intervention efforts better understand the target of the intervention and therefore may improve chances of both scientific and instrumental success.
Publisher: Wiley
Date: 12-2008
DOI: 10.1111/J.1445-2197.2008.04761.X
Abstract: Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision-making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception ('seeing what you believe') were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the 'culture' of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply 'stopping rules' for modifying or converting the operation.
Publisher: Elsevier BV
Date: 08-2016
DOI: 10.1016/J.JTCVS.2016.01.022
Abstract: Checklists are being introduced to enhance patient safety, but the results have been mixed. The goal of this research is to understand why time-outs and checklists are sometimes not effective in preventing surgical adverse events and to identify additional measures needed to reduce these events. A total of 380 consecutive patients underwent complex cardiac surgery over a 24-month period between November 2011 and November 2013 at an academic medical center, out of a total of 529 cardiac cases. Elective isolated aortic valve replacements, mitral valve repairs, and coronary artery bypass graft surgical procedures (N = 149) were excluded. A time-out was conducted in a standard fashion in all patients in accordance with the World Health Organization surgical checklist protocol. Adverse events were classified as anything that resulted in an operative delay, nonavailability of equipment, failure of drug administration, or unexpected adverse clinical outcome. These events and their details were collected every week and analyzed using a systemic causal analysis technique using a technique called CAST (causal analysis based on systems theory). This analytic technique evaluated the sociotechnical system to identify the set of causal factors involved in the adverse events and the causal factors explored to identify reasons. Recommendations were made for the improvement of checklists and the use of system design changes that could prevent such events in the future. Thirty events were identified. The causal analysis of these 30 adverse events was carried out and actionable events classified. There were important limitations in the use of standard checklists as a stand-alone patient safety measure in the operating room setting, because of multiple factors. Major categories included miscommunication between staff, medication errors, missing instrumentation, missing implants, and improper handling of equipment or instruments. An average of 3.9 recommendations were generated for each adverse event scenario. Time-outs and checklists can prevent some types of adverse events, but they need to be carefully designed. Additional interventions aimed at improving safety controls in the system design are needed to augment the use of checklists. Customization of checklists for specialized surgical procedures may reduce adverse events.
Publisher: Oxford University Press
Date: 12-02-2013
Publisher: Emerald
Date: 05-08-2014
Abstract: – The purpose of this paper is to theorize the theory-practice gap and to provide ex les of how it currently expresses itself and how it might be addressed to better integrate between the worlds of thought and praxis. – Two empirical ex les exemplify how the theory-practice gap is an institutionally embodied social reality. Cultural-historical activity theory is described as a means for theorizing the inevitable gap. An ex le from the airline industry shows how the gap may be dealt with in, and integrated into, practice. – Cultural-historical activity theory suggests different forms of consciousness to exist in different activity systems because of the different object/motives in the world in which we think and the practical world in which we live. A brief case study of the efforts of one airline to integrate reflection on practice (i.e. theory) into their on-the-job training shows how the world in which pilots think about what they do is made part of the world in which pilots live. – First, in some cases, such as teacher education, institutional arrangements can be made to situate education/training in the workplace. Second, even in the training systems with high fidelity, high validity (transferability) cannot be guaranteed. – The approach proposed provides a theory not only for understanding the theory-practice gap but also the gap that exists even between very high-fidelity (“photo-realistic”) training situations and the real-world praxis full of surprises.
Publisher: Informa UK Limited
Date: 2000
Publisher: Informa UK Limited
Date: 27-05-2014
Publisher: BMJ
Date: 06-02-2014
DOI: 10.1136/BMJQS-2013-002483
Abstract: There has been much public and media outrage in the wake of the scandal about the standard of healthcare delivered at Stafford Hospital. Using published evidence in the safety literature, we examine the distinction between our need to understand what happened, the practical need for preventing recurrence, and the age-old philosophical need to explain suffering. Investigations of what happened can identify the many detailed explanatory factors behind a particular outcome-including the actions and assessments of in idual caregivers. These, however, do not necessarily constitute the change variables for preventing recurrence, as those might lie elsewhere in the governance of a complex system. And neither says much about the nature and apparent randomness of suffering in the particular circumstances of in idual patients, even if that might be a most pressing question people want answers to in the wake of such a scandal. To promote safety and quality, we encourage a sensitivity to the differences between understanding, satisfying demands for justice, and avoiding recurrence. This might help a just culture in the wake of Mid Staffordshire, as it avoids expectations of an inquiry-independent or public-to do triple duty.
Publisher: Sciedu Press
Date: 28-04-2014
DOI: 10.5430/JHA.V3N5P95
Abstract: Second victims are practitioners involved in an incident that (potentially) harms or kills somebody else, and for which they feel personally responsible. Professional culture and the psychology of blame (and shame) influence how second victims are viewed and dealt with. This paper reviews the status of second victimhood in healthcare – both its symptomatology and organizational responses. Then it considers the problematic nature of “human error” in healthcare and sets this against the psychological backdrop of healthcare professions, seeking cultural-historical explanations in assumptions of actor autonomy and professional identity. It concludes by drawing links between the psychological resilience of the in idual practitioners involved in an incident and the resilience of an organization’s safety culture.
Publisher: Wiley
Date: 08-2008
Publisher: Elsevier BV
Date: 08-2014
Publisher: Springer Science and Business Media LLC
Date: 2004
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-01-2016
Publisher: Springer Science and Business Media LLC
Date: 05-2004
Publisher: Informa UK Limited
Date: 20-02-2014
Publisher: SAGE Publications
Date: 09-05-2014
Abstract: It is a current trend in aviation to use categories of technical (e.g., knowledge) and nontechnical skills (e.g., situation awareness) to assess airline pilots’ performance. Several studies have revealed large disagreement between assessors when airline professionals use these categories to assess the performance of their peers. The aim of the present study is to investigate whether the categories themselves are at the source of disagreement. We explore the reasoning of flight examiners who assess an engine fire scenario in pairs. The results provide insight into the overlap of topics that constitute certain categories. Implications are drawn in regards to the use of assessment categories and their influence on pilot performance assessment.
Publisher: Informa UK Limited
Date: 09-2011
Publisher: Hogrefe Publishing Group
Date: 2013
DOI: 10.1027/2192-0923/A000041
Abstract: Two studies were designed to investigate how pilots of different rank evaluate flight-deck performance. In each study, the pilots were asked to assess sets of three different videotaped scenarios featuring pilots in a simulator exhibiting poor, average, and good performance. Study 1, which included 92 airline pilots of differing rank, was aimed at comparing how in iduals rate performance. The subjects used a standardized assessment form, which included six criteria, each having a 5-point rating scale. Analysis of the first study revealed that there was considerable variance in the performance ratings between flight examiners, captains, and first officers. The second study was designed to better understand the variance. Eighteen pilots (six flight examiners, six captains, and six first officers) working in pairs evaluated performances, in a modified think-aloud protocol. The results showed that there were good reasons for the observed variances. The results are discussed in relation to inter-rater reliability.
Publisher: Elsevier BV
Date: 03-2020
Publisher: BMJ
Date: 07-08-2015
DOI: 10.1136/BMJQS-2014-003106
Abstract: The 'systems approach' to patient safety in healthcare has recently led to questions about its ethics and practical utility. In this viewpoint, we clarify the systems approach by examining two popular misunderstandings of it: (1) the systematisation and standardisation of practice, which reduces actor autonomy (2) an approach that seeks explanations for success and failure outside of in idual people. We argue that both giving people a procedure to follow and blaming the system when things go wrong misconstrue the systems approach.
Publisher: Informa UK Limited
Date: 07-2006
Publisher: BMJ
Date: 03-10-2014
Publisher: Springer Science and Business Media LLC
Date: 29-03-2007
Publisher: SAGE Publications
Date: 03-2010
Abstract: A recent conversation in the literature asks whether human factors constructs amount to folk modeling or to strong science. In this paper we explore this further in the context of well-known positions on the production of science and scientific rationality. We inquire about the sources of epistemological self-confidence—the extent to which human factors is satisfied with its beliefs and assumptions about how it knows what it knows. We question whether a large body of evidence for a construct is evidence of strong science, or whether critical reflection and skepticism about this is actually what distinguishes scientific knowledge from folk models. We also review presumptions of a-perspectival objectivity, in which researchers believe they are able to take a “view from nowhere” and enjoy an objective window onto an existing reality. We ask whether human factors constructs don't so much reflect but rather create a particular empirical world, which would not even exist without those constructs. This article serves as an invitation to rethink what we mean by epistemological confidence and how we arrive at it.
Publisher: Informa UK Limited
Date: 25-11-2013
Publisher: CRC Press
Date: 28-12-2004
Publisher: Institution of Engineering and Technology
Date: 2004
DOI: 10.1049/PBNS032E_CH7
Publisher: Wiley
Date: 28-09-2010
Publisher: Informa UK Limited
Date: 06-2010
Publisher: Elsevier BV
Date: 07-2013
Publisher: Springer Science and Business Media LLC
Date: 24-01-2015
Publisher: Routledge
Date: 29-08-2003
Publisher: Informa UK Limited
Date: 2007
Publisher: Sciedu Press
Date: 19-10-2022
DOI: 10.5430/JHA.V11N2P8
Abstract: Objective: Matching safety and quality improvements to the complexity of healthcare, Gold Coast Mental Health and Specialist Services implemented a new response to clinical incidents: the Gold Coast Clinical Incident Response Framework (GC-CIRF). It utilises a Restorative Just Culture (RJC) framework and Safety II principles. This paper evaluates its impact.Methods: Staff surveys measured perceptions of just culture and second victim experiences. Quality of recommendations were compared before and after implementation. For the 19 incidents that occurred after the implementation of GC-CIRF, audits of the review processes were undertaken, measuring several components.Results: Results show significant improvement in staff perceptions of just culture and second victim experiences. Review of incident review data showed several shifts in line with Safety II and RJC. The process audit demonstrated inclusion of a broad range of stakeholders, and significant improvements in the quality and strength of recommendations.Conclusions: Embedding RJC and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels.
Publisher: Informa UK Limited
Date: 13-11-2008
Publisher: Sciedu Press
Date: 22-03-2013
DOI: 10.5430/JHA.V2N3P73
Abstract: Background: The notion of “just culture” has become a way for hospital administrations to determine employee accountability for medical errors and adverse events. Method: In this paper, we question whether organizational justice can be achieved through algorithmic determination of the intention, volition and repetition of employee actions. Results and conclusion: The analysis in our paper suggests that the construction of evidence and use of power play important roles in the creation of “justice” after iatrogenic harm.
Publisher: Resilience Alliance, Inc.
Date: 2014
Publisher: Informa UK Limited
Date: 2010
Publisher: Informa UK Limited
Date: 04-2003
Start Date: 2014
End Date: 12-2017
Amount: $489,000.00
Funder: Australian Research Council
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