Visar resultat för..."Fram Erik"

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.

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.

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

The complexity of today’s large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective – productivity, quality, safety, etc. – or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does.Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

The complexity of today’s large organisations, businesses, and social institutions defeats management approaches based on monolithic thinking. Most industry and service organisations look at their performance either from a single perspective – productivity, quality, safety, etc. – or from different but separate perspectives that reside in organisational silos. Quality is treated separately from safety, which, again, is treated separately from productivity, and so on. While siloed thinking may be convenient in the short term, it fails to recognise that any specific perspective reveals only a part of what goes on. Yet it is essential to have a unified view of how an organisation functions effectively to manage changes and to ensure the organisation excels in what it does.Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended. It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is consequently not about productivity or quality or safety or reliability but about all of these together. It is about why it is necessary to think of them as a whole. And it is about how this can be done in practice.

This book promotes an understanding of the purposeful muddling that health care workers rely on to be better able to function and operate in the multitude of complex ecosystems we call "health care."The book argues the case for the importance of recognising and understanding muddling behaviours, practices and activities in order to create resilient care. The book demonstrates how resilient health care principles can enable managers as well as those on the frontlines to work more effectively towards interdisciplinary care by gaining a deeper understanding of real-world practices that manifest 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.Primarily aimed at people who are directly involved in the running and improvement of health care systems, it provides practical guidance. It is also of direct interest to health care professionals in clinical and managerial positions as well as researchers.Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Professor of Health Systems Research and Director of the Centre for Healthcare Resilience and Implementation Science, Macquarie University (Australia). His research examines the changing nature of complex health systems and he has received over 50 different national and international awards for his teaching and research.Erik Hollnagel is Senior Professor of Patient Safety at Jönköping University (Sweden). He is a highly regarded international expert with significant contributions to a variety of fields ranging from nuclear power generation, aerospace and aviation to industry, transportation and, most notably, health care.Garthe Hunte is a Clinical Professor and Emergency Physician holding multiple academic and clinical leadership appointments across Canada. His research programme centres around how safety is created in complex socio-technical systems, and in the application of resilience engineering in health care.

This book promotes an understanding of the purposeful muddling that health care workers rely on to be better able to function and operate in the multitude of complex ecosystems we call "health care."The book argues the case for the importance of recognising and understanding muddling behaviours, practices and activities in order to create resilient care. The book demonstrates how resilient health care principles can enable managers as well as those on the frontlines to work more effectively towards interdisciplinary care by gaining a deeper understanding of real-world practices that manifest 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.Primarily aimed at people who are directly involved in the running and improvement of health care systems, it provides practical guidance. It is also of direct interest to health care professionals in clinical and managerial positions as well as researchers.Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Professor of Health Systems Research and Director of the Centre for Healthcare Resilience and Implementation Science, Macquarie University (Australia). His research examines the changing nature of complex health systems and he has received over 50 different national and international awards for his teaching and research.Erik Hollnagel is Senior Professor of Patient Safety at Jönköping University (Sweden). He is a highly regarded international expert with significant contributions to a variety of fields ranging from nuclear power generation, aerospace and aviation to industry, transportation and, most notably, health care.Garthe Hunte is a Clinical Professor and Emergency Physician holding multiple academic and clinical leadership appointments across Canada. His research programme centres around how safety is created in complex socio-technical systems, and in the application of resilience engineering in health care.

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.

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.

Health care is under tremendous pressure regarding efficiency, safety, and economic viability. It has responded by adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability – although with limited, and all-too-often disappointing, results. The Resilient Health Care Network (RHCN) has worked since 2011 to facilitate the interaction and collaboration among practitioners and researchers interested in applying concepts from resilience engineering to health care and patient safety. This has met with considerable success, not least because the focus from the start was on developing concrete ways to complement a Safety-I perspective with a Safety-II perspective.Building on previous volumes, Delivering Resilient Health Care presents documented experiences and practical guidance on how to bring Resilient Health Care into practice. It provides concrete advice on how to prepare a study, how to choose the right data, how to collect it, how to analyse the data, and how to interpret the results. This fourth book in the Resilient Healthcare series contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. This book provides a practical guide for delivering resilient healthcare, particularly for clinicians on the frontline of care unsure how to incorporate resilience into their everyday work, managers coordinating care, and for policymakers hoping to steer the system in the right direction. Other groups – patients, the media, and researchers – will also find much of interest here.

Health care is under tremendous pressure regarding efficiency, safety, and economic viability. It has responded by adopting techniques that have been useful in other industries, such as quality management, lean production, and high reliability – although with limited, and all-too-often disappointing, results. The Resilient Health Care Network (RHCN) has worked since 2011 to facilitate the interaction and collaboration among practitioners and researchers interested in applying concepts from resilience engineering to health care and patient safety. This has met with considerable success, not least because the focus from the start was on developing concrete ways to complement a Safety-I perspective with a Safety-II perspective.Building on previous volumes, Delivering Resilient Health Care presents documented experiences and practical guidance on how to bring Resilient Health Care into practice. It provides concrete advice on how to prepare a study, how to choose the right data, how to collect it, how to analyse the data, and how to interpret the results. This fourth book in the Resilient Healthcare series contains contributions from international experts in health care, organisational studies and patient safety, as well as resilience engineering. This book provides a practical guide for delivering resilient healthcare, particularly for clinicians on the frontline of care unsure how to incorporate resilience into their everyday work, managers coordinating care, and for policymakers hoping to steer the system in the right direction. Other groups – patients, the media, and researchers – will also find much of interest here.

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.

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret

Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret

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.