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Bridging the gap between understanding work-as-imagined and work-as-done in the perioperative work context represents an important aim of cognitive systems engineering research. Researching this context using a joint cognitive systems theoretical approach can reveal patterns of adaptation that have important implications for system design. Traditional research approaches by non-domain investigator
Bakgrund Behandlingsriktlinjer omsätter vetenskaplig evidens till praktiska regler. De är en del av sjukvårdens säkerhetsåtgärder och syftar till att göra vården säker, enhetlig, möjliggör kvalitetskontroll och minskar sjukvårdskostnader. Men det är också viktigt att inte förväxla skapande eller hantering av dokument med att hantera faktisk säkerhet. Ett strikt fokus på följsamhet till regler kan Background: Clinical practice guidelines (CPGs) translate scientific knowledge into practical rules. They aim to improve safety, ensure consistency, enable quality control, and mitigate rising healthcare costs. CPGs and other written instructions are often the target or result of safety interventions in healthcare, but it is important to avoid the trap of managing documents rather than actual safe
The notion of patient safety entails protecting patients from preventable harm. This thesis presents suggestions on how the healthcare system, notably psychiatric healthcare, can understand and analyse patient safety risk as an emergent property of everyday interactions and relations. This view has itsconceptual roots in complexity theory.The overall aim is to understand patient safety risk as an
Som LTH-institution vid Lunds universitet är vi en statlig arbetsgivare som erbjuder en mängd spännande tjänster inom utbildning och forskning. FörmånerFörmåner som ges anställda vid Lunds universitet inkluderar:Förmånlig semester (antal dagar varierar mellan 28 och 35 beroende på ålder)Möjlighet att ha bisysslaRätt till ersättning för viss sjukvård och läkemedelFriskvårdsersättning och en friskvå
https://www.flyg.lth.se/om-oss/jobba-hos-oss - 2026-09-03
This study investigates the concept of Selective Intentional Non-Compliance (SINC) in aviation. Deliberate, context-driven deviations from procedures motivated by safety in response to dynamic operational conditions. Based on a survey of 39 European commercial pilots, we analysed the prevalence, motivations, and perceived outcomes of procedural deviations. Nearly 43% reported deviating from s
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
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
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
This 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
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 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
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 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,
Recent high-visibility disasters have fueled public and political awareness of the importance of managing and mitigating their consequences effectively. In response, various countries have enacted legislation that demands the evaluation of emergency responses so that lessons for improvement can be learned. A series of field and experimental studies were conducted from 2005 to 2007 to assess the ab
This paper questions the correspondance between resilience engineering theory and the theoretical fundaments of traditional CRM training, with its related behavior assessments. Reviewing the theoretical roots of CRM it is concluded that such concepts are rather founded in the information processing paradigm hiding the complexities of adaption to rapidly changing situations. An alternative approach
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, 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
