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Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind ''human error'' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind ''human error'' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind 'human error' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind 'human error' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

Det är inte konstigt att den som landar i Moskva eller Sankt Petersburg utan kunskaper i ryska känner sig handikappad redan i det första gathörnet. Vad betyder CTOP? Att CCCP var detsamma som SSSR minns vi ju från sovjettiden. Men den tog ju slut 1991 ? vad heter Ryssland på ryska? Jo, ROSSIJA, det ser vi i alla idrottssammanhang. Men vad är PECTOPAH? Restaurang, förstås. Men nu börjar det bli svårare. Boken ingår i serien Språk kort och gott. Serien innehåller Fält, Stava dig fram på ryska Fält, 1200 ryska ord till vardags Fält, Rysk miniordlista för turisten Fält, Grekiska från A till O. Grekiska bokstäver och ljud som vi svenskar möter dem Fält, Latinet bakom allt: italiano, español, français

This book focuses on one of the most persistent and controversial questions in modern sociolinguistics: the past and present development of African American Vernacular English (AAVE).

This book focuses on one of the most persistent and controversial questions in modern sociolinguistics: the past and present development of African American Vernacular English (AAVE).

In the coming 20 years, decentralised generation (DG) is expected to play an in- creasingly important role in the European electricity infrastructure and market. DG can be defined as small-scale generation connected to the distribution network or on the customer side of the meter. The application of DG is often highly loca- tion specific and depends on such diverse issues as the possibilities of technical implementation, resource availability, environmental aspects, social embedding of the project, regulation and market conditions. These factors vary considerably among technologies and among the ED Member States. The DECENT study (Decentralised Generation Technologies -Potentials, Suc- cess Factors and Impacts in the Liberalised ED Energy Markets (Joerss et al. 2002" was designed and carried out to identify the main barriers and success fac- tors to the implementation of DG projects within the ED and to formulate a num- ber of related recommendations to ED and Member State policy makers to en- hance the feasibility of DG projects within the internal energy market.

In the coming 20 years, decentralised generation (DG) is expected to play an in- creasingly important role in the European electricity infrastructure and market. DG can be defined as small-scale generation connected to the distribution network or on the customer side of the meter. The application of DG is often highly loca- tion specific and depends on such diverse issues as the possibilities of technical implementation, resource availability, environmental aspects, social embedding of the project, regulation and market conditions. These factors vary considerably among technologies and among the ED Member States. The DECENT study (Decentralised Generation Technologies -Potentials, Suc- cess Factors and Impacts in the Liberalised ED Energy Markets (Joerss et al. 2002" was designed and carried out to identify the main barriers and success fac- tors to the implementation of DG projects within the ED and to formulate a num- ber of related recommendations to ED and Member State policy makers to en- hance the feasibility of DG projects within the internal energy market.

This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers.Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwideEnables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknessesWritten from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical detailsProvides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

The book demonstrates how Resilient Health Care principles can enable those on the frontline to work more effectively towards interdisciplinary care by gaining a deeper understanding of the boundaries that exist in everyday clinical settings. This is done by presenting a set of case studies, theoretical chapters and applications that relate experiences, bring forth ideas and illustrate practical solutions. The chapters address many different issues such as resolving conflict, overcoming barriers to patient-flow management, and building connections through negotiation. They represent a range of approaches, rather than a single way of solving the practical problems, and have been written to serve both a scientific and an andragogical purpose. Working Across Boundaries is primarily aimed at people who are directly involved in the running and improvement of health care systems, providing them with practical guidance. It will also be of direct interest to health care professionals in clinical and managerial positions as well as researchers.Presents the latest work of the lauded Resilient Health Care Net group, developing applications of Resilience Engineering to health care, furthering safety thinking and generating applicable solutions that will benefit patient safety worldwideEnables health care professionals to become aware of the boundaries that affect their work so that they are able to use their strengths and overcome their weaknessesWritten from a Safety-II perspective, where the purpose is to make sure that as much as possible goes well and the focus therefore is on everyday work rather than on failures. There are at present no other books that adopt this perspective nor which go into the practical detailsProvides a concise presentation of the state of resilient health care as a science, in terms of major theoretical issues and practical methods and techniques on the overarching and important topics of boundary-crossing and integration of care settings

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group.

This book is the 3rd volume in the Resilient Health Care series. Resilient health care is a product of both the policy and managerial efforts to organize, fund and improve services, and the clinical care which is delivered directly to patients. This volume continues the lines of thought in the first two books. Where the first volume provided the rationale and basic concepts of RHC and the second teased out the everyday clinical activities which adjust and vary to create safe care, this book will look more closely at the connections between the sharp and blunt ends. Doing so will break new ground, since the systematic study in patient safety to date with few exceptions has been limited.

Resilience Engineering (RE) studies have successfully identified and described many instances of resilient performance in high hazard sectors as well as in the far more frequent cases where people and organisations cope with the uncertainties of daily operations. Since RE was first described in 2006, a steady accumulation of insights and efforts have provided the basis for practical tools and methods. This development has been documented by a series of texts in the Resilience Engineering Perspectives series as well as by a growing number of papers and reports. This book encapsulates the essential practical lessons learned from the use of Resilience Engineering (RE) for over ten years. The main contents are a series of chapters written by those who have been instrumental in these applications. To increase the value for the reader, each chapter will include: rationale for the overall approach; data sought and reason(s) for choosing; data sources used, data analyses performed, and how recommendations were made and turned into practice.Serving as a reference for practitioners who want to analyse, support, and manage resilient performance, this book also advances research into RE by inquiring why work goes well in unpredictable environments, to improve work performance, or compensate for deficiencies.