Erik Hollnagel, David D. Woods and Nancy Leveson (editors)
Explores groundbreaking new development in safety and risk management, where 'success' is based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Featuring contributions from many of the worlds leading figures in the fields of human factors and safety, Resilience Engineering provides provocative insights into system safety.
James Reason:
'This is the most thought-provoking collection of papers I've read in a very long time. They are written by the best in the field at the top of their form. Resilience is a notion whose time has come. We cannot realistically expect to eliminate adverse events and still stay in business. But we can strive to achieve greater robustness towards our operational hazards. This book tells us how to do it and why it's necessary.'
A forthcoming chapter on how sharp end practice bridges gaps to create resilience focused on health care.
What research is needed to advance patient safety? Research to help tame complexity. See a forthcoming handbook chapter to appear in Handbook of Human Factors in Health Care: Taming Complexity pdf
Organized with Erik Hollnagel (University of Linkoping Sweden) and Nancy Leveson (MIT, USA) the International Symposium on Resilience Engineering, October 20-25, 2004, Soderoping Sweden with about 20 participants from over 10 countries.
Symposium Objective
"Research on human reliability, human performance, and organisational aspects of risk and safety have led to the emerging area of Resilience Engineering as an alternative to error tabulations and probabilistic risk management. Resilience Engineering has been proposed as the new field, which enhances organisations’ ability to monitor/revise risk models and to target safety investments proactively despite ongoing production and economic pressures.
The objective of this symposium is to provide an opportunity for experts from around the world to meet and debate the presence and future of Resilience Engineering. Whereas many workshops are characterised by long presentations interrupted by short discussions, this symposium will consist of long discussions interrupted by short presentations."
A brief account of Resilience Engineering: Resilience Engineering Brief pdf
An edited book is being prepared based on the Symposium results.
Contributor to "Organization at the Limit: NASA and the Columbia Disaster" (Blackwell) which provides lessons for all organziations. Download the chapter -- Creating Foresight: Lessons for Enhancing Resilience from Columbia:
creating foresight pdf
Analysis of a medication misadministration and how it reveals generic patterns in collaborative distributed work. In particular the study highlights the role of cross checks in resilience and safety. The study appeared in a special issue of IEEE SMC Part A in November 2004. analysis of a misadministration pdf
Cognitive engineers face the same challenges in designing systems that users confront in working the tasks that the systems are intended to aid. A guide to overcome reductive biases in design. CTW00 pdf
Invited talk Conflicts between Learning and Accountability in Patient Safety.
Presented at the 10th Annual Clifford Symposium on Tort Law and Social Policy. "Starting Over?: Redesigning the Medical Malpractice System." DePaul Law School, Chicago IL, April 15-16, 2004.
Examines how blame-based systems of accountability block information flow and learning, exacerbate double binds and goal conflicts, and degrade cooperation. beyond blame pdf
Testimony to Senate Committee on Commerce, Science and Transportation on the "Future of NASA" following the Columbia accident.
Written testimony: Creating Foresight pdf plus pictures of the hearing at Hearing Pictures html
Press release on Hindsight Bias in learning from Columbia Accident Investigation Board report based Woods' role as consultant to Board. Press Hindsight Bias and Columbia
For how the Columbia Accident reveals other patterns relevant to all organizations, see the preliminary remarks in: 5 Genotypes pdf
Radio interview on WOSU 9-5-03 radio interview mp4
CAIB report available at www.caib.us
9 steps to move forward if you think you have a human error problem: CTW02 pdf
What is Error? On receiving a request for help in defing error in health care, the authors respond with a "Dear Virginnia" letter that reviews some fallacies about error and points to the alternative "Resilience Engineering". "Mistaking Error" D. D. Woods and R. I. Cook. In M. J. Hatlie and B. J. Youngberg (Eds.) Patient Safety Handbook, Jones and Bartlett, 2003, in press. Mistaking error pdf
Series of papers on New Look at Error and the Patient Safety Movement in Health Care:
Future of Patient Safety pdf What is error? pdf Bridging Gaps pdf
Also see: The Pexis e-course on error, Behind the label 'Human Error', and the "The Tale of Two Stories" entries at this site.
For additional results see:
VA Gaps Center web site
Emily Patterson web site
News item on bar coding studies
Universityof Chicago Cognitive technologies Lab site
Cook news item
Electronic course, Behind Human Error -- building Performance Experts in Safety (PEXiS).
error e-course
Primer material on the 'New Look' at error and how complex systems fail:
primer text pdf primer graphics pdf Handbook1 chapter pdf
Reactions to Failure:
error as information pdf Fundamental Surprise pdf
Resilience:
Breakdowns in adaptation pdf Bridging Gaps pdf See 'Moving Forward from Error' at this site.
More on the New Look in the Patient Safety Movement in Health Care:
Future of Patient Safety pdf what is error? pdf See the "The Tale of Two Stories" entry.
Also see: The Pexis e-course on error
Behind the label 'Human Error'
all at this site.
For additional results see:
VA Gaps Center web site
Emily Patterson web site
News item on bar coding studies
Universityof Chicago Cognitive technologies Lab site
For list of papers see: error papers
Scaled world simulation study of professional analysts under data overload.
study of analysts pdf
Produced a variety of design concepts that can seed new support systems. design concepts