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  • 1. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hunte, Garth S.
    Discussion, integration and concluding remarks2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 165-172Chapter in book (Other academic)
  • 2. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Hunte, Garth S.
    Introduction: The journey to here and what happens next2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 3-8Chapter in book (Other academic)
  • 3. Braithwaite, Jeffrey
    et al.
    Hollnagel, ErikJönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.Hunte, Garth S.
    Working across boundaries: Resilient health care, volume 52019Collection (editor) (Other academic)
  • 4. Braithwaite, Jeffrey
    et al.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Wears, Robert L.
    Bon voyage: Navigating the boundaries of resilient health care2019In: Working across boundaries: Resilient health care, volume 5 / [ed] J. Braithwaite, E. Hollnagel & G. S. Hunte, London: CRC Press, 2019, , p. 192p. 9-14Chapter in book (Other academic)
  • 5.
    França, Josué E.M.
    et al.
    UFF (Universidade Federal Fluminense), Rio de Janeiro, Brazil.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Dos Santos, Isaac José Antonio Luquetti
    IEN (Instituto de Energia Nuclear), Rio de Janeiro, Brazil.
    Haddad, Assed N.
    UFRJ (Universidade Federal do Rio de Janeiro), Rio de Janeiro, Brazil.
    FRAM AHP approach to analyse offshore oil well drilling and construction focused on human factors2019In: Cognition, Technology & Work, ISSN 1435-5558, E-ISSN 1435-5566Article in journal (Refereed)
    Abstract [en]

    Since the beginning of the well-drilling activities of oil and gas industry, in the 19th century, these activities have presented specific risks that, over the course of their evolution to the present day, have greatly increased their potential to cause harm to people, the environment, and corporate sustainability. Stimulated by the world’s energy needs, especially in developed and growing countries, the technology used by the O&G industry has evolved significantly, not only to increase production and profit levels, but also to reduce the risks of these activities, using reliable automation and other barriers to worker protection. However, despite all this investment, accidents such as the Deepwater Horizon, in 2010, and Odebrecht NS-32, in 2017, shown that there are still gaps in this process of evolution of protection systems, especially those used in highly complex systems such as offshore oil rigs. In addition, inevitably, the technological contribution implemented in offshore drilling systems increases their complexity and, consequently, also increases the complexity of the relationship between workers, systems, machines, and environment, definitively characterizing oil rigs as complex socio-technical systems. Keeping that in mind, a FRAM model was developed to understand the levels of complexity and show the relevant human factors that are critical for the safe operations of these workplaces, considering the natural and variability that emerges from these labour scenarios. Some functions of the FRAM model built presented significant variability, as function “Perform drilling operations”, where the most significant variabilities were observed in its 10 outputs, causing a large resonance within the model, once their couplings, mostly in their control aspects, can vary in terms of time and precision.

  • 6.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    FRAM. Metodo de Analisi della Risonanza Funzionale per costruire modelli di sistemi socio-tecnici e spiegare l'accadimento di eventi2019Book (Other academic)
  • 7.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Safety-II の実践 ―レジリエンスポテンシャルを強化する2019Book (Other academic)
  • 8.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    The gilded age?2019In: Safety science research: Evolution, challenges and new directions / [ed] J.-C. Le Coze, Boca Raton: CRC Press, 2019Chapter in book (Other academic)
    Abstract [en]

    This chapter describes the world as black or white and uses that as the basis of explanations and communication. A strategy of depth-before-breadth makes it possible to pursue a single idea until the objective has been achieved, while at the same time limiting the mental effort required. The main issue with safety – and the reason why it is an ever-growing problem – is that the lack of safety is neither due to a single factor, nor can it be comprehended by a single view. A contemporary approach to safety should recognise that; it should try to embrace multiple perspectives in a comprehensible way. Since the focus of safety is on the negative, on what goes wrong or fails, the efforts focus on how to eliminate the causes. New perspectives and new approaches are brought on to solve the old problems, but the problems are understood in the same way, at times with a sprinkle of complexity added.

  • 9.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Vad händer när ingenting händer?2019In: Säker vård - nya perspektiv på patientsäkerhet / [ed] Synnöve Ödegård, Stockholm: Liber, 2019, p. 75-86Chapter in book (Other academic)
  • 10.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Macleod, Fiona
    The imperfections of accident analysis2019In: Loss Prevention Bulletin, ISSN 0260-9576, E-ISSN 1744-358X, no 270, p. 2-6Article in journal (Refereed)
  • 11.
    Hollnagel, Erik
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Sujan, M.
    Human Reliability Associates Ltd, United Kingdom.
    Braithwaite, J.
    Macquarie University, Australia.
    Resilient Health Care – Making steady progress2019In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 120, p. 781-782Article in journal (Refereed)
  • 12.
    Jonassen, Jan R.
    et al.
    Western Norway University of Applied Sciences, Haugesund, Norway.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    License to intervene: the role of team adaptation in balancing structure and flexibility in offshore operations2019In: WMU Journal of Maritime Affairs (JoMA), ISSN 1651-436X, E-ISSN 1654-1642, WMU Journal of Maritime Affairs, Vol. 18, no 1, p. 103-128Article in journal (Refereed)
    Abstract [en]

    The study reported here reviewed and analyzed multi-team organizations in offshore operations to identify and understand the factors that are essential for good operation. It was found that the most prominent contribution to good operations was the balancing of structure and flexibility during work (anchor handling operations). The enabling factor towards this balance seems to be a process of team adaptation, including adjustments and corrections, when performing operations. The multi-teams operate in an open climate with a commonly accepted allowance to stop any safety-threatened operational activity. In practice, this gives the operational teams a “license” to intervene and adjust or adapt to suddenly occurring anomalies. The operations are in turn based on a period of planning and preparing. During the actual balancing, the teams relied on communication and information sharing, coordination and cooperation, and anticipation (proactive behavior) and empowerment/autonomy as effective enablers of team adaptation. 

  • 13.
    Sujan, Mark Alexander
    et al.
    Human Reliability Associates, Dalton, United Kingdom.
    Furniss, Dominic
    Human Reliability Associates, Dalton, United Kingdom.
    Anderson, Janet E.
    King's College London, United Kingdom.
    Braithwaite, Jeffrey
    Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Resilient Health Care as the basis for teaching patient safety – A Safety-II critique of the World Health Organisation patient safety curriculum2019In: Safety Science, ISSN 0925-7535, E-ISSN 1879-1042, Vol. 118, p. 15-21Article in journal (Refereed)
    Abstract [en]

    Resilient Health Care (RHC)is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout. 

  • 14.
    Thude, Bettina Ravnborg
    et al.
    Department of Centre for Quality, Region Syddanmark Center for Kvalitet, Middelfart, Denmark.
    Juhl, Andreas Granhof
    Institute for Communications, Århus Universitet, Aarhus, Denmark.
    Stenager, Egon
    Department of Neurology, Hospital of Southern Jutland, Focused Research Unit in Neurology, Aabenraa, Denmark.
    von Plessen, Christian
    Department of Regional Health Research, University of Southern Denmark, Sønderborg, Denmark.
    Hollnagel, Erik
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Staff acting resiliently at two hospital wards2019In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887, Vol. 32, no 3, p. 445-457Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The purpose of this paper is to understand how the hospital staff (nurses and physicians) at two hospital wards have coped with everyday work having leaders in conflict or longer periods without one or the other leader and whether the way the staff handled the challenges was resilient.

    DESIGN/METHODOLOGY/APPROACH: Through semi-structured interviews with the staff at the two wards, the authors analysed how the staff were working, if they had cooperation and interdisciplinary cooperation, how they would handle uncertainties and how they coped with the absence of their leaders.

    FINDINGS: The staff at both wards were handling the everyday work in a resilient way. The authors argue that to increase the resilience in an organisation, leaders should acknowledge the need to establish strong emotional ties among staff and at the same time ensure role structures that make sense in the everyday work.

    ORIGINALITY/VALUE: This study reports on original work and shows what decision makers could do to increase resilience in an organisation. This paper shows that the organisational context is important for the staff to act resiliently. As leaders come and go, it can be important for the stability of the organisation to promote the staff in acting resiliently independent of the leader situation.

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