Plan study do act patient identified as sdb cpapmad therapy improvement in ef and ntprobnp improvement in quality of life subjective prospective consecutive patient enrolment. Erik hollnagel, 2011 understanding accidents, or how not to learn from the past professor erik hollnagel university of southern denmark odense, denmark. Introduction when most people hear the word safety they. Resilient health care evokes a sort of enlightenment about how the healthcare industry might be. Tom mcdaniel, global manager zero harm and human performance, siemens energy, inc. Erik hollnagel, 2018 black holes and matter in the safety universe erik hollnagel, ph. He argues that safety management must look ahead and not only try to avoid things going wrong, but also try to ensure that they go right. Improving performance reliability in surgical systems. Erik hollnagel has been full professor of humanmachine interaction at linkaping university s, since 1999. Once you have installed adobe air, you just rightclick on the fmv file and select open. Charles perrow, erik hollnagel and robert helmreich have written extensively on the subject.
A white paper executive summary the publication of the iom report to err is human in 2000 served as a catalyst for a growing interest in improving the safety of health care. Senior researcher, department manager, and later principal scientist, computer resources international. In relation to health care, the team led by david woods at ohio university, us and that led by charles vincent at st marys hospital, london have done much of the pioneering and development work in adapting the approach to medicine. Erik hollnagel nov20, by erik hollnagel deals you better of life that can create the top quality of the life brighter. Erik hollnagel studies multicriteria decision analysis, ship hydrodynamics, and ethnographic fieldwork. Safety ii is more than just incident and accident prevention. In an attempt to prevent future accidents, there is an underlying assumption shorrock, 2014 for this somewhat peculiar emphasis, which is. Erik hollnagel, 2015 some myths about industrial safety erik hollnagel professor, university of southern denmark email. Barriers and accident prevention, or how to improve safety by. Hollnagel then turns to root causes and as we will see erik not too fond of the term root cause, or at least of some of its mainstream applications. This acclaimed book by erik hollnagel is available at in several formats for your ereader. Technical document prepared by the industrial safety chair.
Erik hollnagel, phd university of southern denmark the history of safety management can be seen as a series of proposals for antidotes to the occurrences of accidents, incidents, and adverse outcomes in general. Resilience engineering as an approach to safety for industry and society. Safetyi and safetyii, the past and future of safety management find, read and. Abstract resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress. Erik hollnagel cselab, department of computer and information science university of linkoping, se58183 linkoping, sweden email.
Pdf the publication of the iom report to err is human in 2000 served as a. Erik hollnagel, 2014 the causality credo 1 adverse outcomes happen because something has gone wrong causes. Rollenhagen and erik hollnagel whatyoulookforiswhatyoufind the consequences of underlying accident models in eight accident investigation manuals safety science, 2009, 47, 129711. Erik has for many years worked at universities, research centres, and industries in several countries and with problems. The handbook is available for downloading pdfformat. Safetyi and safetyii fram etto synesis resilience engineering. Developing the resilience potentials ebook written by erik hollnagel. Download fulltext pdf download fulltext pdf barrier analysis and hollnagels functional resonance accident model article pdf available december 2008 with 75 reads.
Safety is the state in which harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of. Erik hollnagel, 2010 causality in simple systems if a physician make a large incision with an operating knife and cure it, or if he open a tumor. Whenever an accident happens there is a natural concern to find out in detail exactly what happened and to determine the causes of it. Previously principal advisor, oecd halden reactor project, norway 19951999. Erik hollnagel, 2012 resilience engineering and crisis management erik hollnagel, professor, ph. This document is published by eurocontrol for information purposes. Erik hollnagel professor, university of southern denmark chief consultant, centre for quality, region of southern denmark email.
Now available from ashgate publishing resilient health care. Erik hollnagel, 20 resilience engineering as an approach to safety for industry and society erik hollnagel, professor, ph. Pdf barrier analysis and hollnagels functional resonance. Yet despite decades of attention, activity and investment, improvement has been glacially slow. The bumpy road to better risk control mary kay oconnor. Edited by erik hollnagel, university of southern denmark, jeffrey braithwaite, university of new south wales, australia and robert l. The antidotes have necessarily been relative to the commonly agreed causes of harm and injury. Patient safety in everyday work, improving patient safety by investigating how health care professionals perform everyday work. Hollnagelsafety science 46 2008 221229 when considering how to respond to an accident, it is. This video is about rb day 1 10 professor erik hollnagel. Erik hollnagel, robert l wears, jeffrey braithwaite. Physician quality improvement summit november 19, 2018. Section 2 applied cognition in human technical systems.
Erik hollnagel nov20, by erik hollnagel is just what individuals currently need. A white paper on resilience engineering for atm eurocontrol. Pdf on the use of flight operating procedures for the. Erik hollnagel, 2011 causality in simple systems if a physician make a large incision with an operating knife and cure it, or if he open a tumor. Download for offline reading, highlight, bookmark or take notes while you read safetyi and safetyii. Woods and nancy leveson other recommended books by john kotter the heart of change. Indeed, the use of flight pro files can allow the identification of p arts of flights that make sense from a crew perspective and can then be mined to extract outliers. Indeed, whenever the result of an action or event falls significantly short of what was expected. Erik hollnagel, 2016 different work processes work is typically focused. Erik hollnagel, 2014 safetyi when nothing goes wrong safety is the condition where the number of adverse outcomes accidents incidents near. Understanding accidents, or how not to learn from the past. This tool helps modelling the the fram table and visualize it.
A functioncentred approach to joint drivervehicle system design. In this thought paper, professor erik hollnagel explores the importance of proactive approaches to safety management. He has published more than 350 papers and authored or edited 20 books, some of the most recent titles being resilient health care ashgate, 20, the functional resonance analysis method ashgate, 2012, and resilience engineering in practice ashgate, 2011. Rag resilience analysis grid introduction erik hollnagel. Erik hollnagel, 2011 resilience engineering and safety management erik hollnagel email. Their combined citations are counted only for the first article. A visualizer for fram functional resonance accident model, a jcsmodel developed by erik hollnagel at liu, sweden.
Erik hollnagel professor, university of southern denmark e. Practitioners from various fields, such as aviation and air traffic management, patient safety, offshore exploration and production, have quickly realised the potential of. Resilience is an expression of how people, alone or together, cope an organizations performance can be said to be resilient if it can. Download for offline reading, highlight, bookmark or take notes while you read safetyii. Denmarks professor erik hollnagel explains why safety management should move to ensuring that as many things as possible go right safety in action 2014. Reallife stories of how people change their organizations buyin. The past and future of safety management ebook written by erik hollnagel. Analysis of errors from week 2 week 5 chapter 7 comprehension and situation awareness francis t. Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Indeed, although it has been instrumental towards a systemic and organisational perspective on.
A great passage from erik hollnagels barriers and accident prevention on the search for causes. Erik hollnagel resilience is an expression of how people, alone or together, cope an organizations performance can be said to be resilient if it can function as required under expected and unexpected conditions alike. Scale invariance is a feature of structures or functions that does not change when the scale changes. His main message is that accident investigation often stops too early, at a convenient or arbitrary point. In an attempt to prevent future accidents, there is an underlying assumption shorrock, 2014 for. Erik hollnagel is also editorinchief of ashgate studies in resilience engineering. How to be safe by looking at what goes right instead of.
Erik hollnagel, safetyi and safetyii most traditional accident investigations tend to focus on discovering things around an event that never actually happened. Resilience engineering as an approach to safety for industry. The reason for this understanding of safety is not hard to find. The sia national safety convention offers ohs professionals an unparalleled opportunity to keep up to date with the latest national and international developments 18 24. Lunds university, sweden lundberg j, rollenhagen c, hollnagel e 2009. Scope and purpose of the study it is now broadly recognized that accidents in complex systems occur through the concatenation of.
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