Braithwaite Jeffrey - The resilience of everyday clinical work

RESILIENT HEALTH CARE, VOLUME 2

Series Editors

Professor Erik Hollnagel, Institute of Public Health,
University of Southern Denmark, Denmark

Professor Sidney Dekker, Key Centre for Ethics, Law, Justice and Governance,
Griffith University, Brisbane, Australia

Dr Christopher P. Nemeth, Principal Scientist, Cognitive Solutions Division
(CSD) of Applied Research Associates, Inc. (ARA), Fairborn, Ohio, USA

Dr Yushi Fujita, Technova, Inc., Japan

Resilience engineering has become a recognized alternative to traditional approaches to safety management. Whereas these have focused on risks and failures as the result of a degradation of normal performance, resilience engineering sees failures and successes as two sides of the same coin as different outcomes of how people and organizations cope with a complex, underspecified and therefore partly unpredictable environment.

Normal performance requires people and organizations at all times to adjust their activities to meet the current conditions of the workplace, by trading-off efficiency and thoroughness and by making sacrificing decisions. But because information, resources and time are always finite such adjustments will be approximate and consequently performance is variable. Under normal conditions this is of little consequence, but every now and then and sometimes with a disturbing regularity the performance variability may combine in unexpected ways and give rise to unwanted outcomes.

The Ashgate Studies in Resilience Engineering series promulgates new methods, principles and experiences that can complement established safety management approaches. It provides invaluable insights and guidance for practitioners and researchers alike in all safety-critical domains. While the Studies pertain to all complex systems they are of particular interest to high-hazard sectors such as aviation, ground transportation, the military, energy production and distribution, and healthcare.

The Resilience of Everyday Clinical Work

Edited by
ROBERT L. WEARS
University of Florida Health Science Center, USA
ERIK HOLLNAGEL
University of Southern Denmark
JEFFREY BRAITHWAITE
Macquarie University, Australia

ASHGATE

Robert L. Wears, Erik Hollnagel and Jeffrey Braithwaite 2015

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher.

Robert L. Wears, Erik Hollnagel and Jeffrey Braithwaite have asserted their rights under the Copyright, Designs and Patents Act, 1988, to be identified as the editors of this work.

Published by

Ashgate Publishing Limited

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England

Ashgate Publishing Company

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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library

The Library of Congress has cataloged the printed edition as follows:
Resilient health care. Volume 2, The resilience of everyday clinical work / [edited]
by Robert L. Wears, Erik Hollnagel and Jeffrey Braithwaite.

p. ; cm. -- (Ashgate studies in resilience engineering)

Resilience of everyday clinical work

Includes bibliographical references.

ISBN 978-1-4724-3782-2 (v. 2 : hardback) -- ISBN 978-1-4724-3783-9 (v. 2 : ebook) -- ISBN 978-1-4724-3784-6 (v. 2 : epub)

I. Wears, Robert L., editor. II. Hollnagel, Erik, 1941- , editor. III. Braithwaite, Jeffrey, 1954- , editor. IV. Title: Resilience of everyday clinical work. V. Series: Ashgate studies in resilience engineering.

[DNLM: 1. Quality of Health Care--organization & administration. 2. Clinical Medicine--methods. 3. Efficiency, Organizational. 4. Patient Safety. W 84.4] RA971

362.1068--dc23

2014033829

ISBN: 9781472437822 (hbk)

ISBN: 9781472437839 (ebk-PDF)

ISBN: 9781472437846 (ebk-ePUB)

Garth S. Hunte

Mark A. Sujan, Peter Spurgeon and Matthew W. Cooke

Deborah Debono and Jeffrey Braithwaite

Kristin Laugaland and Karina Aase

Mirjam Ekstedt and Richard I. Cook

Robert L. Wears, Christiane C. Schubert and Garth S. Hunte

Denham Phipps, Darren Ashcroft and Dianne Parker

Kazue Nakajima

Jeffrey Braithwaite and Jennifer Plumb

Robert J. Stephens, David D. Woods and Emily S. Patterson

Erik Hollnagel

Shawna J. Perry and Rollin J. Fairbanks

Rob Robson

Sam Sheps, Karen Cardiff, Elaine Pelletier and Rob Robson

Christiane C. Schubert, Robert L. Wears, Richard J. Holden and Garth S. Hunte

Sheuwen Chuang and Robert L. Wears

Al Ross and Janet E. Anderson

Erik Hollnagel

Robert L. Wears (MD; MS, computer science; PhD, industrial safety) is Professor of Emergency Medicine at the University of Florida Health Science Center Jacksonville, and Visiting Professor in the Clinical Safety Research Group, Imperial College London. He is a practicing emergency physician and has since 1994 been studying safety in healthcare settings. His specific areas of interest include resilience in small work teams, response to the unexpected, the design of artefacts to support distributed cognition, and the impact of computerized information technology on safety and performance. He has authored over 250 papers, book chapters, and essays, the most recent title being Patient Safety: A Brief but Spirited History (in Zipperer, Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer; Gower, 2014). He is Senior Associate Editor of Annals of Emergency Medicine, and serves on the Editorial Boards of Human Factors and the Journal of Patient Safety. He is also a member of the Board of Directors of the Emergency Medicine Patient Safety Foundation.

Erik Hollnagel (PhD, psychology) is Professor at the University of Southern Denmark, Chief Consultant at the Centre for Quality Improvement, Region of Southern Denmark, and Professor Emeritus at University of Linkping (Sweden). He has since 1971 worked at universities, research centres, and industries in several countries, most recently as Industrial Safety Chair at MINES ParisTech (France). He has worked with problems from many domains including nuclear power generation, off-shore, aerospace and aviation, air traffic management, software engineering, healthcare, and land-based traffic. His professional interests include industrial safety, resilience engineering, accident investigation, cognitive systems engineering and cognitive ergonomics. He has published more than 250 papers and authored or edited 20 books, some of the most recent titles being The Functional Resonance Analysis Method (Ashgate, 2012), Governance and Control of Financial Systems (Ashgate, 2011), Resilience Engineering in Practice (Ashgate, 2011), The ETTO Principle (Ashgate, 2009). Erik is also Editor-in-chief of Ashgate Studies in Resilience Engineering.