Repentance as Rebuke: Betrayal and Moral Injury in Safety Engineering.

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.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework.

OBJECTIVE: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. METHOD: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. RESULTS: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. CONCLUSIONS: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

Examining the asymptote in safety progress: a literature review.

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.

"Loss of situation awareness" by medical staff: reflecting on the moral and legal status of a psychological concept.

This article examines the emergence of "accurate situation awareness (SA)" as a legal and moral standard for judging professional negligence in medicine. It argues that SA constitutes a status, an outcome resulting from the confluence of a wide array of factors, some originating inside and others outside the agent. SA does not connote an action, a practice, a role, a task, a virtue, or a disposition--the familiar objects of moral and legal appraisal. The argument contends that invoking SA becomes problematic when its use broadens to include professional or legally appraisable norms for behaviour, which expect a certain state of awareness from practitioners.

Ergonomics and sustainability: towards an embrace of complexity and emergence.

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. PRACTITIONER SUMMARY: 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.

The social process of escalation: a promising focus for crisis management research.

BACKGROUND: This study identifies a promising, new focus for the crisis management research in the health care domain. After reviewing the literature on health care crisis management, there seems to be a knowledge-gap regarding organisational change and adaption, especially when health care situations goes from normal, to non-normal, to pathological and further into a state of emergency or crisis. DISCUSSION: Based on studies of escalating situations in obstetric care it is suggested that two theoretical perspectives (contingency theory and the idea of failure as a result of incomplete interaction) tend to simplify the issue of escalation rather than attend to its complexities (including the various power relations among the stakeholders involved). However studying the process of escalation as inherently complex and social allows us to see the definition of a situation as normal or non-normal as an exercise of power in itself, rather than representing a putatively correct response to a particular emergency. IMPLICATIONS: The concept of escalation, when treated this way, can help us further the analysis of clinical and institutional acts and competence. It can also turn our attention to some important elements in a class of social phenomenon, crises and emergencies, that so far have not received the attention they deserve. Focusing on organisational choreography, that interplay of potential factors such as power, professional identity, organisational accountability, and experience, is not only a promising focus for future naturalistic research but also for developing more pragmatic strategies that can enhance organisational coordination and response in complex events.

What is rational about killing a patient with an overdose?: enlightenment, continental philosophy and the role of the human subject in system failure.

This paper raises the issue of ergonomics' role in giving primacy to fully rational individual 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 individual 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.

Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage?

ABSTRACT: Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction-that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes about risk and risk reduction/prevention, as well as the model's incompatibility with work in healthcare. We consider how these problems lead to interruptions interventions with unintended negative consequences. Then, we examine possible alternatives, viz organizing work for high reliability, preventing safety drift, and engineering resilience into the work activity. These all approach risks in different ways, and as such, propose interruptions interventions that are vastly different from interventions based on the barrier model. The purpose of this article is to encourage a different approach for designing interruptions interventions. Such reflection may help healthcare communities innovate beyond old, ineffective, and often counterproductive interventions to handle interruptions.

[Does Dutch medical disciplinary law fit within Safety II?] / Kwaliteit van zorg en het recht.

Dutch medical disciplinary law aims to promote quality of care. Safety II is a scientific approach to quality promotion that is increasingly being adopted in the Dutch healthcare system. We compared both approaches. Safety II recognises that doctors act based on efficiency-thoroughness trade-offs and identifies factors that lead to success. Disciplinary law answers culpable actions with disciplinary measures. We conclude that for Safety II, the distinction between culpable and inculpable is meaningless, while the disciplinary approach mainly provides a negative warning function. Safety II is better suited for medical practice, because healthcare is complex and benefits from a high degree of discretion. Disciplinary law should therefore be given a role that facilitates more reflection on success factors. The fact that it can take action against doctors who perform poorly does not detract from that: Safety II fulfils this function better because it does not wait for something to go wrong but acts proactively.

A Systems Approach to Analyzing and Preventing Hospital Adverse Events.

OBJECTIVE: This study aimed to demonstrate the use of a systems theory-based accident analysis technique in health care applications as a more powerful alternative to the chain-of-event accident models currently underpinning root cause analysis methods. METHOD: A new accident analysis technique, CAST [Causal Analysis based on Systems Theory], is described and illustrated on a set of adverse cardiovascular surgery events at a large medical center. The lessons that can be learned from the analysis are compared with those that can be derived from the typical root cause analysis techniques used today. RESULTS: The analysis of the 30 cardiovascular surgery adverse events using CAST revealed the reasons behind unsafe individual behavior, which were related to the design of the system involved and not negligence or incompetence on the part of individuals. With the use of the system-theoretic analysis results, recommendations can be generated to change the context in which decisions are made and thus improve decision making and reduce the risk of an accident. CONCLUSIONS: The use of a systems-theoretic accident analysis technique can assist in identifying causal factors at all levels of the system without simply assigning blame to either the frontline clinicians or technicians involved. Identification of these causal factors in accidents will help health care systems learn from mistakes and design system-level changes to prevent them in the future.

Hindsight bias and outcome bias in the social construction of medical negligence: a review.

Medical negligence has been the subject of much public debate in recent decades. Although the steep increase in the frequency and size of claims against doctors at the end of the last century appears to have plateaued, in Australia at least, medical indemnity costs and consequences are still a matter of concern for doctors, medical defence organisations and governments in most developed countries. Imprecision in the legal definition of negligence opens the possibility that judgments of this issue at several levels may be subject to hindsight and outcome bias. Hindsight bias relates to the probability of an adverse event perceived by a retrospective observer ("I would have known it was going to happen"), while outcome bias is a largely subconscious cognitive distortion produced by the observer's knowledge of the adverse outcome. This review examines the relevant legal, medical, psychological and sociological literature on the operation of these pervasive and universal biases in the retrospective evaluation of adverse events. A finding of medical negligence is essentially an after-the-event social construction and is invariably affected by hindsight bias and knowledge of the adverse outcome. Such biases obviously pose a threat to the fairness of judgments. A number of debiasing strategies have been suggested but are relatively ineffective because of the universality and strength of these biases and the inherent difficulty of concealing from expert witnesses knowledge of the outcome. Education about the effect of the biases is therefore important for lawyers, medical expert witnesses and the judiciary.

Benefactor or burden: Exploring the professional identity of safety professionals.

INTRODUCTION: The professional identity of safety professionals is rife with unresolved contradictions and tensions. Are they advisor or instructor, native or independent, enforcer of rules or facilitator of front-line agency, and ultimately, a benefactor for safety or an organizational burden? Perhaps they believe that they are all of these. This study investigated professional identity through understanding what safety professionals believe about safety, their role within organizations, and their professional selves. Understanding the professional identity of safety professionals provides an important foundation for exploring their professional practice, and by extension, understanding organizational safety more broadly. METHOD: An embedded researcher interviewed 13 senior safety professionals within a single large organization. Data were analyzed using grounded theory methodology. The findings were related to a five-element professional identity model consisting of experiences, attributes, motives, beliefs, and values, and revealed deep tensions and contradictions. This research has implications for safety professionals, safety professional associations, safety educators, and organizations.

Criminalization of medical error: who draws the line?

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.

Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery.

This paper shows how discontinuities in the process of drug delivery enable but also underdetermine the isolation of a culprit in adverse medication events. A case example illustrates how we are forced to abandon conceptualizations of blame that assume a dichotomy (either culpable or not), and shift instead to a more nuanced version that estimates the degree to which an actor desired, generated, or could have foreseen the harmful outcome, and the extent to which constraints external to the actor altered the event. The paper concludes that meaningful safety interventions in a system as diverse, socially embedded and complex as health care delivery cannot just build on "good science" (e.g., good methods) to generate "root" causes. Rather, they need to somehow be sensitive to how and which narratives of success and failure are created, as these constrain which countermeasures are likely to be encouraged, funded, and accepted.

Rasmussen's legacy and the long arm of rational choice.

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 individual 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.

When a checklist is not enough: How to improve them and what else is needed.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

The systems approach to medicine: controversy and misconceptions.

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 individual people. We argue that both giving people a procedure to follow and blaming the system when things go wrong misconstrue the systems approach.