Abstract
Frameworks in which we think and facilitate learning experiences about safe operations in healthcare are essential for planning for and practicing safety management. The community of practitioners who study safe operations has for some time described the danger of preponderantly focusing on information from safety reporting systems. Yet in practice there is a tendency towards this very preoccupation. Furthermore, we have not experienced learning environments designed to challenge this presupposition or encourage learners to critically reflect on the effect that institutionalized thinking may have on work-as-done in patient safety management. This paper describes a learning experience designed to interactively and incrementally invite collective discussion into diverse conceptualizations of safety. We review limitations and the subsequent influence of these conceptualizations of safety on systems design. The success of these conversations will be defined by how future generations think about and piece together this puzzle we call safety.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Hollnagel, E.: Is safety a subject for science? Saf. Sci. 67, 21–24 (2014)
National Academies of Sciences, Engineering, and Medicine (NASEM): How People Learn II: Learners, Contexts, and Cultures. National Academies Press (2018)
Watts, B.V., et al.: Curriculum development and implementation of a national interprofessional fellowship in patient safety. J. Patient Saf. 14(3), 127–132 (2018)
NHS Blood and Transplant. The Strange Case of Penny Allison: Patient Blood Management England [Video file], 18 August 2017. https://www.youtube.com/watch?v=1VKt2LysGxA
Merigó, J.M., Miranda, J., Modak, N.M., Boustras, G., De La Sotta, C.: Forty years of safety science: a bibliometric overview. Saf. Sci. 115, 66–88 (2019)
Rasmussen, J.: Risk management in a dynamic society: a modelling problem. Saf. Sci. 27(2–3), 183–213 (1997)
Reason, J.T.: Managing the Risks of Organizational Accidents. Ashgate Publishing Limited, Aldershot (1997)
Le Coze, J.C.: Reflecting on Jens Rasmussen’s legacy. A strong program for a hard problem. Saf. Sci. 71, 123–141 (2015)
Le Coze, J.C.: New models for new times. An anti-dualist move. Saf. Sci. 59, 200–218 (2013)
Russ, A.L., Militello, L.G., Saleem, J.J., Wears, R.L., Fairbanks, R.J., Karsh, B.T.: Human factors education for healthcare audiences: ideas for the way forward. In: Proceedings of the Human Factors and Ergonomics Society Annual Meeting, vol. 55, no. 1, pp. 808–812. SAGE Publications, Los Angeles, September 2011
Williams, L., Watts, B.V., McKnight, S., Bagian, J.P.: Human factors and ergonomics in patient safety curriculum. Hum. Factors Ergon. Manufact. Serv. Ind. 22(1), 64–71 (2012)
Seagull, F.J., Greenberg, G.M.: Inter-professional human factors education: democratizing safety and quality. In: Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care, vol. 4, no. 1, pp. 165–167. SAGE Publications, New Delhi, June 2015
Morel, G., Amalberti, R., Chauvin, C.: Articulating the differences between safety and resilience: the decision-making process of professional sea-fishing skippers. Hum. Factors 50(1), 1–16 (2008)
Fuller, H.J., Bagian, T.M.: Task excursion analysis: matching the tool to the user, environment, and task. In: Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care, vol. 3, no. 1, pp. 203–206. SAGE Publications, Los Angeles, June 2014
Miller, K., Bagian, T., Williams, L.: Human factoring healthcare: making human factors more accessible. In: Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care, vol. 3, no. 1, pp. 191–195. SAGE Publications, Los Angeles, June 2014
Nystrom, D.T., Williams, L., Paull, D.E., Graber, M.L., Hemphill, R.R.: A theory-integrated model of medical diagnosis. J. Cogn. Eng. Decis. Making 10(1), 14–35 (2016)
Estock, J.L., Murray, A.W., Mizah, M.T., Mangione, M.P., Goode, J.S., Jr., Eibling, D.E.: Label design affects medication safety in an operating room crisis: a controlled simulation study. J. Patient Saf. 14(2), 101 (2018)
Le Coze, J.C.: How safety culture can make us think. Saf. Sci. 118, 221–229 (2019)
Gunnar, W., Soncrant, C., Lynn, M.M., Neily, J., Tesema, Y., Nylander, W.: The impact of surgical count technology on retained surgical items rates in the veterans health administration. J. Patient Saf. 16(4), 255–258 (2020)
Acknowledgments
We would like to thank everybody at the VHA National Center for Patient Safety, patient safety fellows, and fellowship faculty for their commitment to patient safety. Also, we thank B.V. Watts for providing the academic framework and leading past learning activities towards a collective understanding of these concepts. There were no relevant financial relationships or any source of support in the forms of grants, equipment, or drugs. The authors declare no conflict of interest. The opinions expressed in this article are those of the authors and do not necessarily represent those of the Department of Veterans Affairs.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2021 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this paper
Cite this paper
Arnold, T., Fuller, H.J.A., Gilman, S.C., Gunnar, W.P. (2021). How Might We Think About Safety? Inviting Deeper Reasoning Through Elaborative Inquiry. In: Kalra, J., Lightner, N.J., Taiar, R. (eds) Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. AHFE 2021. Lecture Notes in Networks and Systems, vol 263. Springer, Cham. https://doi.org/10.1007/978-3-030-80744-3_8
Download citation
DOI: https://doi.org/10.1007/978-3-030-80744-3_8
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-80743-6
Online ISBN: 978-3-030-80744-3
eBook Packages: EngineeringEngineering (R0)