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Over-reliance in high-risk industries on prescriptive emergency procedures and the capacity of high-fidelity simulation has initiated the search for new steps for training for unexpected and escalating situations. This chapter outlines a theoretical framework describing the adaptive and flexible competencies that add up to an organisation’s resilience in escalating situations. To make the framewor
Analyzes of the terrorist attack on Drottninggatan have begun to be published. The risk is now that the debate will be governed by the logic of hindsight, that politicians and the media will be on the stands, pointing out mistakes and demand responsibility. Such a climate jeopardizes in the long run the development of our ability to prevent terrorist attacks, write four security researchers.
Recent accidents such as the Macondo blowout actualize the issue of offshore safety. Accidents do occur in spite of actions taken to prevent them from happening. The energy-barrier philosophy is the governing principle within the Norwegian offshore industry. The paradox with that philosophy is that the construction of additional barriers may increase complexity within the system. Risk may be seen
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.
This report presents a protocol for assessing team performance in terms of control based on cognitive systems engineering theories. The protocol changes the focus of team performance assessment from good and bad behaviours towards the team’s activity. By using Hollnagel’s contextual control model (COCOM) a protocol is developed so that team activity can be categorised into four control modes. Data
The Aviation industry is ultra-safe. Rules and procedures have been attributed as a contributory factor for attaining this high level of safety. The complexity of the aviation system has risen dramatically in the last few decades due to the development and introduction of modern aircraft and on-board technological innovations. Every day pilots encounter situations they did not expect. During those
Improving teamwork has become a major safety goal for healthcare organizations. Audit tools currently available are useful, but they remain inadequate because they are reactive and fail to provide context for “the interaction between people and the operational context (i.e., organizational, regulatory and environmental factors) within which people discharge their operational duties” (Maurino, 2005
Effektiv kommunikation av riskbilden i länet mellan länsstyrelsen och allmänheten Examensarbetets slutsats är att länsstyrelsen borde samverka med kommunerna i en dialogbaserad kommunikation med allmänheten. Länsstyrelsen bör även försöka fylla de, i examensarbetet, identifierade kunskapsluckorna, vilka även kan utgöra framtida examensarbeten. Information av riskbilden till allmänheten är ett växThis master thesis deals with how an effective risk communication between the county administrative board and the public can be conducted. The master thesis starts with a summary of the current literature on the subject after which interviews were conducted with three individuals who work with these issues at the county administrative board in Kalmar and a number of questions were sent to a few mu
System-thinking and related systemic methods enhance traditional risk and hazard assessments and accident analysis, as well as system design. The Functional Resonance Analysis Method (FRAM) is a recently developed method for systemic analysis. FRAM facilitates descriptions of the functional relations among system elements. In case of large systems (e.g. several agents, multiple procedures, many te
The thesis explores the migration experiences of Syrian refugees who arrived in Sweden and Denmark by crossing the Mediterranean Sea in small, precarious boats. It aims to illuminate how these refugees managed the risks they faced during their journey to Europe and the meanings they associated with these risks. The research focuses on the socio-cultural and individual contexts within which risk is
Mountain communities are adapting their livelihoods to a complex combination of social, political and economic changes and associated risks. Despite recognition of adaption in response to multiple changes in sustainable livelihood and critical climate change literature, risks attributed to biophysical effects of climate change have increasingly assumed importance. Consequently, diversification is
LTH, 6 mars 2020 Om något allvarligt händer Det är viktigt att du som prefekt informerar LTH:s rektor och kommunikationschef, liksom LU:s säkerhetschef, om alla allvarliga händelser – detta utan fördröjning! Aktuella telefonnummer hittar du nedan. LTH-nummer som ska finnas lättillgängliga/i mobilen (ej för spridning på grund av en del privata mobilnummer) Lunds universitets larmtelefon Om du behöv
https://www.lu.se/sites/www.lu.se/files/t_f_kort_om_kris_telefonboken_mars_2020.docx - 2026-06-05
Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amou
In this study, principles of Cognitive Systems Engineering are used to better understand the human–machine interaction manifesting in the use of anaesthesia alarms. The hypothesis is that the design of the machine incorporates built-in assumptions of the user that are discrepant with the anaesthesiologist's self-assessment, creating ‘user image mismatch’. Mismatch was interpreted by focusing on th
The aim of the thesis was to study the information retrieval and seeking of an on-scene commander on the incident site. Also, to systematize the information to further improve the decision-making condition for all all of the commanding officers. By studying literature, analysing collected recorded material from helmet-mounted cameras and conducting interviews, the study has shown that commanders,
In this study, the duality of adaptive capacity in aviation safety is examined, where the need for resilience of frontline workers conflicts with the expectations and assumptions of upstream entities, leading to system brittleness. We explore three critical categories: responsibilization, the application of practical wisdom in navigating challenging situations, and the unrecognized sacrifices that
Background: Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human – Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology.Methods: A bibliometric analysis was performed
Resilience is becoming a prevalent agenda in safety research and organisational practice. In this study we examine how the peer-reviewed safety science literature (a) formulates the rationale behind the study of resilience; (b) constructs resilience as a scientific object; and (c) constructs and locates the resilient subject. The results suggest that resilience engineering scholars typically motiv
In society, accidents happen on a daily basis. To investigate these accidents is part of preventing them from happening at all. The investigations are carried out by different reasons and with different focus as well as by varying methods and extent. This contributes to that the finding of causes of the event varies with the investigator as well as with what the purpose of the investigation is as
