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.

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.

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.

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.

"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.

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.

A just culture after Mid Staffordshire.

There has been much public and media outrage in the wake of the scandal about the standard of healthcare delivered at Stafford Hospital. Using published evidence in the safety literature, we examine the distinction between our need to understand what happened, the practical need for preventing recurrence, and the age-old philosophical need to explain suffering. Investigations of what happened can identify the many detailed explanatory factors behind a particular outcome-including the actions and assessments of individual caregivers. These, however, do not necessarily constitute the change variables for preventing recurrence, as those might lie elsewhere in the governance of a complex system. And neither says much about the nature and apparent randomness of suffering in the particular circumstances of individual patients, even if that might be a most pressing question people want answers to in the wake of such a scandal. To promote safety and quality, we encourage a sensitivity to the differences between understanding, satisfying demands for justice, and avoiding recurrence. This might help a just culture in the wake of Mid Staffordshire, as it avoids expectations of an inquiry-independent or public-to do triple duty.

Setting culture apart: distinguishing culture from behavior and social structure in safety and injury research.

The concept of culture is now widely used by those who conduct research on safety and work-related injury outcomes. We argue that as the term has been applied by an increasingly diverse set of disciplines, its scope has broadened beyond how it was defined and intended for use by sociologists and anthropologists. As a result, this more inclusive concept has lost some of its precision and analytic power. We suggest that the utility of this "new" understanding of culture could be improved if researchers more clearly delineated the ideological - the socially constructed abstract systems of meaning, norms, beliefs and values (which we refer to as culture) - from concrete behaviors, social relations and other properties of workplaces (e.g., organizational structures) and of society itself. This may help researchers investigate how culture and social structures can affect safety and injury outcomes with increased analytic rigor. In addition, maintaining an analytical distinction between culture and other social factors can help intervention efforts better understand the target of the intervention and therefore may improve chances of both scientific and instrumental success.

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.

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.

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.

Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.

Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision-making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception ('seeing what you believe') were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the 'culture' of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply 'stopping rules' for modifying or converting the operation.

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.

Doctors are more dangerous than gun owners: a rejoinder to error counting.

OBJECTIVE: This paper analyzes some of the problems with error counting as well as the difficulty of proposing viable alternatives. BACKGROUND: Counting and tabulating negatives (e.g., errors) are currently popular ways to measure and help improve safety in a variety of domains. They uphold an illusion of rationality and control but may offer neither real insight nor productive routes for improving safety. METHOD: The paper conducts a critical analysis of assumptions underlying error counting in human factors. RESULTS: Error counting is a form of structural analysis that focuses on (supposed) causes and consequences; it defines risk and safety instrumentally in terms of minimizing negatives and their measurable effects. In this way, physicians can be proven to be 7500 times less safe than gun owners, as they are responsible for many more accidental deaths. CONCLUSION: The appeal of error counting may lie in a naive realism that can enchant researchers and practitioners alike. Supporting facts will continue to be found by those looking for errors through increasingly refined methods. APPLICATION: The paper outlines a different approach to understanding safety in complex systems that is more socially and politically oriented and that places emphasis on interpretation and social construction rather than on putatively objective structural features.