scholarly journals Systemic Approach to Failure Analysis: A Study of Sociotechnical Organization

2022 ◽  
Vol 8 (2) ◽  
pp. 108-124
Author(s):  
Nasir Afghan
Keyword(s):  
Financial Crisis ◽  
Safety Culture ◽  
Radioactive Source ◽  
Near Miss ◽  
Systemic Approach ◽  
Major Incident ◽  
Future Research ◽  
Industrial Services ◽  
Unsafe Behaviors ◽  
Back Door

The paper is an attempt to explore systemic approach to accidents analysis within sociotechnical organization. Unsafe behaviors can result in systemic failures and accidents. The research data came from within an industrial radiography organization where radiation source is used to detect cracks or hidden flaws within machinery and welding joints. The radioactive source can cause severe detrimental effects, even death, if not used safely. This paper is on two isolated events happen in the same company, Industrial Services Private Limited (not real name). The company top management was dealing with the financial crisis and to maintain quality of its services and the safety of staff. The leadership of the company made several business and operational decisions to manage the financial crisis. During that time, several near miss incidents took place, but the first major incident took place when the radiography gamma projector, along with the radioactive source, fallen out of the vehicle because of improper back door closure of the vehicle. In the second incident, the radioactive source remained unshielded after a radiography job, this caused overexposure to radiography workers. The paper provides an opportunity to understand how an organization’s leadership can create conditions for errors and mistakes that result in poor safety culture and ultimately the accident which resulted the system failure and operation shutdown. The paper also tries to propose a conceptual framework to improve safety culture within the sociotechnical systems for the future research in this area.

scholarly journals Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department ‘near miss’ for breathlessness: a strengths-based qualitative study

BMJ Open ◽  
2017 ◽  
Vol 7 (12) ◽  
pp. e017536 ◽  
Author(s):  
Tim Luckett ◽  
Jane Phillips ◽  
Miriam Johnson ◽  
Maja Garcia ◽  
Priyanka Bhattarai ◽  
...  
Keyword(s):  
Emergency Department ◽  
Self Efficacy ◽  
Near Miss ◽  
Self Management ◽  
Integrative Approach ◽  
Future Research ◽  
Management Approach ◽  
Chronic Obstructive ◽  
Pharmacological Management ◽  
Near Misses

ObjectivesBreathlessness ‘crises’ in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED ‘near misses’ where they considered going to the ED but successfully self-managed instead.Design and methodsA qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen’s Transactional Model of Stress and Coping informed interpretive themes.ResultsInterviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services.ConclusionsIn addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients’ generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

Safety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review

2017 ◽  
Vol 41 (2) ◽  
pp. 279-304 ◽  
Author(s):  
Seung Eun Lee ◽  
Linda D. Scott ◽  
V. Susan Dahinten ◽  
Catherine Vincent ◽  
Karen Dunn Lopez ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Literature Review ◽  
Safety Culture ◽  
Theoretical Framework ◽  
Future Research ◽  
Units Of Analysis ◽  
Care Outcomes ◽  
Collection Methods

This integrative literature review was conducted to examine the relationships between safety culture and patient safety and quality of care outcomes in hospital settings and to identify directions for future research. Using a search of six electronic databases, 17 studies that met the study criteria were selected for review. This review revealed semantic inconsistencies, infrequent use of a theory or theoretical framework, limited discussions of validity of instruments used, and significant methodological variations. Most notably, this review identified a large array of nonsignificant and inconsistent relationships between safety culture and patient safety and quality of care outcomes. To improve understanding of the relationships, investigators should consider using a theoretical framework and valid measures of the key concepts. Researchers should also give more attention to selecting appropriate sampling and data collection methods, units of analysis, levels of data measurement and aggregation, and statistical analyses.

The Global Financial Crisis: what have we learned so far?

2015 ◽  
Vol 11 (2) ◽  
pp. 134-161 ◽  
Author(s):  
Karyn L. Neuhauser
Keyword(s):  
Financial Crisis ◽  
Large Scale ◽  
Global Financial Crisis ◽  
Financial System ◽  
Future Research ◽  
Financial Assets ◽  
Content Type ◽  
The Subject ◽  
The Global Financial Crisis ◽  
Number Of Citations

Purpose – The purpose of this paper is to provide a cohesive review of the major findings in the literature concerning the Global Financial Crisis. Design/methodology/approach – Papers published in top-rated finance and economics journal since the crisis up to the present were reviewed. A large number of these were selected for inclusion, primarily based on the number of citations they had received adjusted for the amount of time elapsed since their publication, but also partly based on how well they fit in with the narrative. Findings – Much has been done to investigate the causes of the Global Financial Crisis, its effects on various aspects of the financial system, and the effectiveness of regulatory measures undertaken to restore the financial system. While more remains to be done, the existing body of research paints an interesting picture of what happened and why it happened, describes the interrelationships between the mortgage markets and financial markets created by the large scale securitization of financial assets, identifies the problems created by these inter-linkages and offers possible solutions, and assesses the effectiveness of the regulatory response to the crisis. Originality/value – This study summarizes a vast amount of literature using a framework that allows the reader to quickly absorb a large amount of information as well as identify specific works that they may wish to examine more closely. By providing a picture of what has been done, it may also assist the reader in identifying areas that should be the subject of future research.

scholarly journals Diversity across EU banking sectors: Poorly researched and underappreciated

2018 ◽  
Vol 87 (4) ◽  
pp. 153-179
Author(s):  
Hans-Helmut Kotz ◽  
Dorothea Schäfer
Keyword(s):  
Financial Crisis ◽  
Sovereign Debt ◽  
Large Scale ◽  
Goodness Of Fit ◽  
Banking Sector ◽  
Financial Sector ◽  
Future Research ◽  
Banking Union ◽  
The European Union ◽  
Research Gaps

Zusammenfassung: Das Interesse an der Rolle der Vielfalt im Bankensektor hat erheblich zugenommen, seit die Finanzkrise (und die anschließenden Staatsschuldenkrisen) die europäischen Länder in unterschiedlicher Weise getroffen haben. In diesem Überblicksartikel werden entscheidende Forschungslücken im Bereich der Vielfalt im Bankensektor herausgearbeitet. Vorbereitend dazu bilanzieren wir die Vielfalt der Bankensektoren in der Europäischen Union und beleuchten die Unterschiede vor und nach der Finanzkrise. Kernpunkte einer künftigen Forschungsagenda zur Bewertung der Diversität im Bankensektor (und im Finanzsektor im Allgemeinen) sind: (a) die Definition der empirischen Bedeutung des Konzepts und damit seiner messbaren Eigenschaften, (b) die Beziehung zwischen Diversität und Wettbewerbsniveau (Marktmacht) im Bankensektor, (c) die Verbindung zwischen Diversität und Stabilität des Bankensektors, (d) die Relevanz der Diversität im Bankensektor für einen erleichterten Zugang zu Finanzierung, insbesondere für KMU, und (e) die Verknüpfungen zwischen Diversität im Bankensektor (Finanzsektor) und nichtfinanzieller, „realer“ wirtschaftlicher Diversität („Goodness of fit“-Problematik, institutionelle Einbettung). Die aufgezeigten Forschungslücken zu schließen, wäre ein wichtiger Beitrag sowohl zur Debatte über eine tiefere Integration der europäischen Finanzmärkte (Bankenunion, Kapitalmarktunion) als auch zur Debatte über eine nachhaltige Finanzarchitektur, die gleichzeitig Innovation und Wachstum fördert und die Gesellschaft wirksam vor großen Finanzkrisen schützt. Summary: Interest in the role of diversity in banking sectors has increased substantially since the financial crisis (and the subsequent sovereign debt crises) have hit European countries differentially. The purpose of this note is to hint at crucial research gaps in terms of appreciating consequences of this variety. In preparation for this, we take stock of the across country diversity of banking sectors in the European Union before and after the financial crisis. Key issues in a future research agenda for evaluating diversity in the banking sector (and the financial sector more generally) have to do with: (a) defining the concept’s empirical meaning and hence its measurable properties, (b) the relationship between diversity and the level of competition (market power)in the banking sector, (c) the link between diversity and banking sector stability, (d) the pertinence of banking sector diversity for mitigating access to finance problems, in particular for SMEs and (e) the interlinkages between diversity in the banking (financial) sector and non-financial, “real” economy diversity (“goodness of fit”-issue, institutional embededdness). Filling the indicated research gaps would be an important contribution to both the debate on deeper integration of Europe’s financial markets (Banking Union, Capital Markets Union)as well as the debate on a sustainable financial architecture, being at the same time conducive to innovation and growth whilst protecting society effectively from large-scale financial crises.

scholarly journals Modyfikacje systemów gwarantowania depozytów bankowych w konsekwencji globalnego kryzysu finansowego

2015 ◽  
Vol 1 (3) ◽  
pp. 243-258
Author(s):  
Marcin Gospodarowicz
Keyword(s):  
Financial Crisis ◽  
Global Financial Crisis ◽  
Safety Net ◽  
Systemic Approach ◽  
Regulatory Action ◽  
Present Stage ◽  
Guarantee System ◽  
The Global Financial Crisis ◽  
Two Stages ◽  
Financial Safety Net

The article attempts to review the changes in the deposit guarantee systemresulting from the global financial crisis. There were two stages of regulatorychanges. One in the initial years of the crisis (2008-2009) when the changes werereactive in nature and focused in particular on raising the guarantee limits andrelief operations. As can be seen from the example of regulatory action in theEuropean Union, the present stage of changes in the deposit guarantee system ischaracterized by a systemic approach which attempts to position anew depositguarantees in the context of the financial safety net, particularly against thedevelopment of resolution procedures.

The frequency, types and causes of medical device-related errors reported in the literature: a Rapid Review (Preprint)

2020 ◽  
Author(s):  
Emilia Anderson ◽  
Simon Poon ◽  
Jonathan Penm
Keyword(s):  
Medical Device ◽  
Medical Devices ◽  
Improve Patient Safety ◽  
Near Miss ◽  
Rapid Review ◽  
Future Research ◽  
Surgical Equipment ◽  
Cardiovascular Devices ◽  
Automated External Defibrillators ◽  
Design Error

BACKGROUND The use of medical devices is rapidly expanding. Despite this, there is a huge gap in the literature surrounding the use of devices in healthcare and the adverse events occurring. Given that these errors can be life-threatening, it is imperative to have a thorough understanding of the problem in order to improve patient safety. OBJECTIVE To conduct a Rapid Review to identify the frequency, types and causes of medical device-related errors which are reported in published peer-reviewed literature. METHODS Following PRISMA guidelines, a literature search strategy was developed. Databases searched until 23 February 2018 included Pubmed, International Pharmaceutical Abstracts and Cinahl. Articles were included if they: defined medical devices, reported the frequency, causes and types of errors, were published in peer-reviewed literature. Articles were screened and discussed by two authors. RESULTS Database searching yielded 7,559 unduplicated articles. After two rounds of screening, 24 articles were included in the Review. Device types included cochlear implants, defibrillator leads, anaesthetic & intensive care devices, surgical equipment, automated external defibrillators, radiation oncology devices, ambulance stretchers, breast pumps, cardiovascular devices, orthopaedic devices, and patient controlled analgesia devices. The frequency of errors was 3.83-33.0%. The most common causes were user error, malfunction and design error. CONCLUSIONS This Review identified a range of device types associated with errors. The frequency of errors was lower than published literature. User error was confirmed as a leading cause, alongside malfunction and design error. Future research should examine near-miss events and expand the device types studied.

THE EFFECT OF SAFETY CLIMATE AND CULTURE ON SAFETY PERFORMANCE: AN EXAMPLE OF A MEDICAL FACULTY HOSPITAL ABSTRACT

2021 ◽  
Vol 0 (41) ◽  
pp. 0-0
Author(s):  
Kevser TUNCER KARA ◽  
A. Ferdane OĞUZÖNCÜL
Keyword(s):  
Linear Regression ◽  
Safety Culture ◽  
Safety Climate ◽  
Linear Regression Analysis ◽  
Medical Faculty ◽  
Safety Performance ◽  
Near Miss ◽  
Occupational Accidents ◽  
Multivariate Linear Regression Analysis ◽  
Simple Linear Regression

Aim: The aim of this study was to investigate factors affecting safety climate, safety culture, safety performance, and the effect of safety climate and culture on safety performance in Fırat University Medical Faculty Hospital. Method: The population of this cross-sectional, descriptive study consisted of doctors, midwives, nurses and other medical staff (1454 people) working at Fırat University Medical Faculty Hospital. The minimum sample size of the study was calculated as 616 with a 95% confidence interval and 3% margin of error using the Epi Info program. The data were collected through a questionnaire consisting of personal information form, safety climate scale, safety culture scale and safety performance scale. The Kolmogrov-Smirnov, Man-Whitney U, Kruskal Wallis, chi-square test, ROC, internal reliability, simple linear regression and multivariate linear regression analysis were used in data analysis. Results: The median age of the participants was 31.0. Of the participants, 50.6% were women, 61.9% were married and 38.0% had graduate or higher levels of education. It was determined that those who had information on occupational accidents and diseases had higher perceptions of safety climate, safety culture and safety performance. Furthermore, safety climate, safety culture and safety performance were positively correlated. As a result of simple linear regression, it was determined that the security climate explained 12.1% and the security culture 17.6% of security performance. Conclusion: It was concluded that trainings should be increased and repeated periodically, reporting near-miss events should be facilitated. Finally, occupational health and safety unit should be established, and inspections should be increased.

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