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- Akselsson, Roland, et al.
(författare)
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Efficient and effective learning for safety from incidents
- 2012
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Ingår i: Work. - 1051-9815 .- 1875-9270. ; 41, s. 3216-3222
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Tidskriftsartikel (refereegranskat)abstract
- Learning from incidents is important for improving safety. Many companies spend a great deal of time and money on such learning procedures. The objectives of this paper are to present some early results from a project aimed at revealing weaknesses in the procedures for learning from incidents and to discuss improvements in these procedures, especially in chemical process industries. The empirical base comes from a project assessing organizational learning and the effectiveness of the different steps of the learning cycle for safety and studying relations between safety-specific transformational leadership, safety climate, trust, safety-related behavior and learning from incidents. The results point at common weaknesses in the organizational learning, both in the horizontal learning (geographical spread) and in vertical learning (double-loop learning). Furthermore, the effectiveness in the different steps of the learning cycle is low due to insufficient information in incident reports, very shallow analyses of reports, decisions that focus at solving the problem only at the place where the incident took place, late implementations and weak solutions. Strong correlations with learning from incidents were found for all safety climate variables as well as for safety-related behaviors and trust. The relationships were very strong for trust, safety knowledge, safety participation and safety compliance.
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| 2. |
- Akselsson, Roland
(författare)
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Human Factors and Sustainable Development - Some Lessons from Human Factors and Safety Management
- 2010
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Ingår i: Neue Arbeits- und Lebenswelten gestalten. - 9783936804089 ; , s. 437-440
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Konferensbidrag (refereegranskat)abstract
- Mankind is already spending beyond the capacity of its planet and trends look very scaring. Big changes in human behaviour are urgent. As pointed out by others there are many ways how Ergonomics/Human Factors/ could contribute to such changes. The aim of this paper is to discuss some lessons learnt from safety performance in aviation and trans¬formed to sustainability, especially the concepts sustainability management systems and resilience sustainability cultures adapted to different levels of the global socio-technical-economic system and to different contexts.
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| 4. |
- Fyhr, AnnSofie, et al.
(författare)
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Characteristics of medication errors with parenteral cytotoxic drugs.
- 2012
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Ingår i: European Journal of Cancer Care. - : Hindawi Limited. - 1365-2354 .- 0961-5423.
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Tidskriftsartikel (refereegranskat)abstract
- FYHR A. & AKSELSSON R. (2012) European Journal of Cancer Care Characteristics of medication errors with parenteral cytotoxic drugs Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the patient. The most commonly involved cytotoxic drugs were fluorouracil, carboplatin, cytarabine and doxorubicin. The platinum-containing drugs often caused serious consequences for the patients. The most common error type were too high doses (45%) followed by wrong drug (30%). Twenty-five of the medication errors (42%) occurred when doctors were prescribing. All of the preparations were delivered to the patient causing temporary or life-threatening harm. Another 25 of the medication errors (42%) started with preparation at the pharmacies. The remaining 10 medication errors (16%) were due to errors during preparation by nurses (5/60) and administration by nurses to the wrong patient (5/60). It is of utmost importance to minimise the potential for errors in the prescribing stage. The identification of drugs and patients should also be improved.
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| 5. |
- Fyhr, AnnSofie, et al.
(författare)
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Misstag med koncentrerade kalium- och natriumlösningar. Analys och lärdomar av anmälda ärenden
- 2011
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Ingår i: Läkartidningen. - 0023-7205. ; 108:16-17, s. 923-927
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Tidskriftsartikel (refereegranskat)abstract
- I en retroaktiv kvalitativ analys av 32 lex Maria- och HSAN-ärenden har vi undersökt vad som hände, bakomliggande orsaker och vilka lärdomar som finns. Konsekvenserna för patienterna var i flera fall allvarliga, med dödsfall, livshotande arytmier och svåra hudnekroser. Att förpackningarna liknade varandra var en vanlig bakomliggande orsak till misstagen. Hemsjukvården svarade för nästan en tredjedel av ärendena. Svårigheter att kunna arbeta ostört, dålig belysning och läkemedel som placeras olämpligt var bokomliggande orsaker. Lokala åtgärder som rekommenderas är bl a att begränsa tillgången till koncentrerade elektrolyter, speciellt kalium, och att upphandla för säkerhet. Nationellt behövs samarbete mellan läkemedelsindustrin, Läkemedelsverket och Socialstyrelsen för att förbättra förpackningarna, vilket minskar risken för fel. Erfarenheter från händelseanalyser och lex Maria-ärenden ska hanteras lokalt men bör också aggregeras på nationell nivå för att dra lärdom och för effektiva motåtgärder.
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| 6. |
- Jacobsson, Anders, et al.
(författare)
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Learning from incidents - A method for assessing the effectiveness of the learning cycle
- 2012
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Ingår i: Journal of Loss Prevention in the Process Industries. - : Elsevier BV. - 0950-4230. ; 25:3, s. 561-570
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Tidskriftsartikel (refereegranskat)abstract
- Abstract in UndeterminedThis paper describes a method for assessing the effectiveness in the steps of the learning cycle: the 1st loop with reporting - analysis - decision - implementation - follow-up, and the 2nd loop on an aggregated basis. For each step, the dimensions considered the most relevant for the learning process (scope, quality, timing and information distribution) and for each dimension the most relevant aspects (e.g. completeness and detail) were defined. A method for a semi-quantitative assessment of the effectiveness of the learning cycle was developed using these dimensions and aspects and scales for rating. The method will give clear indications of areas for improvement when applied. The results of the method can also be used for correlation with other safety parameters, e.g. results from safety audits and safety climate inquiries. The method is intended to be used on a sample of the broad range of incidents normally seen in process industry companies. The method was tested on a two-year incident reporting material from six companies from various types of process industries. It was found that the method and the tools worked very well in practice. The results gave interesting insights into the effectiveness of learning from the incidents.
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| 8. |
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| 9. |
- Jacobsson, Anders, et al.
(författare)
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Method for evaluating learning from incidents using the idea of "level of learning"
- 2011
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Ingår i: Journal of Loss Prevention in the Process Industries. - : Elsevier BV. - 0950-4230. ; 24:4, s. 333-343
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Tidskriftsartikel (refereegranskat)abstract
- Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be ques-tioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.
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| 10. |
- Koornneef, Floor, et al.
(författare)
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Bringing SMS in Aviation to Life by Human Integration: Building on the Basis of ICAO SMS and Transitioning away from a Static Regulatory Approach
- 2010
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Ingår i: [Host publication title missing]. - 9781450715560
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Konferensbidrag (refereegranskat)abstract
- The ICAO approach to risk management is essentially a technical model based on an engineering process viewpoint and is more applicable in concept to stable systems, such as chemical and nuclear industries. If airlines are to manage risk in a proactive manner they need to apply risk detection tools that provide real time and continuous systems oversight. This paper describes briefly the systems approach applied to the development and implementation of a dynamic Safety Management System (SMS) in a major airline in Europe with a focus on management of operational risks. This work has been realized as a part of the in the FP6 HILAS project. The SMS principally consists of a Risk Management System (RMS) and a Safety Assurance process. Principles of Organizational Learning and Resilient Safety Culture have been adhered to throughout this development. As a result, the RMS is conceived as an aspect system with functions, actors, supporting processes and connecting data streams. The work in progress demonstrates that integrating humans in processes of risk management leads to bridging expertise domains, enables improved business controls and efficiencies, as well as safety risks.
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