Rasmussen, Jens

Rasmussen, Jens. Approaches to the control of the effects of human error on chemical plant safety. In International Symposium on Preventing Major Chemical Accidents, American Inst, of Chemical Engineers, February 1987. 

Rasmussen, Jens. 1990. Human error and the problem of causality in analysis of accidents. In Human Factors in Hazardous Situations, ed. D. E. Broadbent, J. Reason, and A. Baddeley, 1-12. Oxford Clarendon Press. 

Rasmussen, Jens. Risk management in a dynamic society A modelling problem. Safety Science 27 (2/3) (1997) 183-213. 

Rasmussen, Jens, Keith Duncan, and Jacques Leplat. 1987. New Technology and Human Error. New York John Wiley Sons. 

Rasmussen, Jens, and Annelise Mark Pejtersen. 1995. Virtual ecology of work. In An Ecological Approach to Human Machine Systems I A Global Perspective, ed. J. M. Flach, P. A. Hancock, K. Caird, and K. J. cente, 121-156. Hillsdale, NJ Erlbaum. 

Rasmussen, Jens, and Inge Svedung. 2000. Proactive Risk Management in a Dynamic Society. Stockholm Swedish Rescue Services Agency. 

Reimer KA, Lowe JE, Rasmussen MM, Jennings RB. The wavefront phenomenon of ischemic cell death I. 

Reimer K, Lowe J, Rasmussen M, Jennings R. The wave front phenomenon of ischemic cell death. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation 1977 56 786. 

This book returns to these early ideas and updates them for today s technology. It also builds on the pioneering work in Europe of Jens Rasmussen and his followers in applying systems thinking to safety and human factors engineering. 

After an entire chapter on error, it may seem still more curious, even perverse, to ask whether the concept of error is useful for patient safety. The heading comes from the title of a chapter written by Jens Rasmussen (Rasmussen, 1997), whose work has influenced every field of safety and who has been a maj or influence on many of the leading figures in patient safety. We cannot do more than hint at some of his ideas here, but they will set the scene for later chapters on creating safety. 

System-oriented studies of the normal cognition and behavior of individuals and the work environment are replacing studies that count error as the target for patient safety research. Researcher Jens Rasmussen, noting problems with the concept of human error (for example, the notion is hard to define and is a function of the biases of the observer), believes that error is only an indication of experts exploring the boundaries of acceptable performance in an unkind environment (Rasmussen, 1998, p. 4), and believes (p. 3) that safety depends on the control of work processes to avoid accidental side effects causing harm to people, environment, or investment. ... 

First, we make a general acknowledgment to major contributors to the field of patient safety whose work we have drawn on for this book. Among them are James Reason, Karl Weick, Jens Rasmussen, Richard Cook, David Woods, and Karlene Roberts. Special thanks to Lucian Leape for writing the Foreword he has been not only a pioneer in the field but also a mentor. Don Berwick, president of the Center for Healthcare Improvement, and Jim Conway, chief operating officer of the Dana-Farber Cancer Institute, both in Boston, have made substantial contributions through their work, which appears in this book. 

Other authors like Jens Rasmussen ([14], [15]) distinguish between different levels of human performance and correlate them to required attention and familiarity with the task, cf. Fig.5. It is evident that knowledge-based actions are associated with the highest error probability, but most actions required from a car driver are rule based like obeying traffic signs, or skill-based like changing the gears. 

Two classifications emerged from the nuclear context which have become the most widely accepted and used. One arose from the work led by Jens Rasmussen in Denmark and the second from the work of Jim Reason and colleagues in the UK (see, for example, Rasmussen, 1987 Reason, 1987). These two classifications are outlined in Sections 2.1 and 2.2 below. 

Jens Rasmussen is a visionary engineer, self-taught in human factors, who is capable of reading and bridging different streams of theory that are mutually unaware of each other. He refocused his career on technical and human reliability after the nuclear accident which occurred at Three Mile Island in the United States in March 1979. He was to become one of the pioneers of modern approaches to safety in complex systems and went on to have a profound influence on a whole generation of researchers who studied directly under him, such as James Reason, Erik Hollnagel, Dave Woods, and... the author of this book. 

James Reason was Professor at the University of Manchester for many years, and is now retired he is no doubt the best-known theoretical author on human error. He has published a number of works, one of which is the reference work on this subject he was strongly influenced by Jens Rasmussen, with whom he worked closely in the mid-1980s. 

---