Safety practices causation models

PROFESSIONAL SAFETY PRACTICE REQUIRES ESTABLISHING AN ACCEPTED CAUSATION MODEL... 

Safety professionals apply differing and contradictory incident causation models, and the work of some of them is misdirected and ineffective. Professional safety practice requires that the advice given to avoid, eliminate, or control hazards be based on a sound incident causation model, a thought process, so that, through the application of that model, the desired risk reduction is attained. That will not occur if the causation model used does not require identifying the actual causal factors. 

A practice of safety based principally on the many extensions of the causation model represented by the domino sequence developed by H. W. Heinrich that focus on the so-called unsafe act or human error as the principal causal factor will be ineffective in relation to the actuality of causal factors. 

Often, the wrong advice is given when the causation model on which the practice of safety is based focuses primarily and almost exclusively on ... 

It s proposed that safety professionals can benefit from a review of the causation models on which their practices are based. For those who would undertake such an exercise toward the development of an acceptable causation model for hazards-related incidents, the following are recommended as noinimal readings ... 

Professional safety practice requires that the advice given be based on a sound hazards-related incident causation model so that, through the application of that advice, hazards are effectively avoided, eliminated, or controlled and risks are reduced. 

In Chapter 3, Serious Injury Prevention, an outline for such a study was presented under the heading Proposing a Study of Serious Injuries. Such a study will not be time-consuming since the data to be collected and analyzed should already exist or can be obtained easily. To assist in such a study, two addenda are provided at the conclusion of this chapter. Both are reprinted Ifom the third edition of On The Practice Of Safety Addendum A, A Systemic Causation Model for Hazards-Related Incidents, and Addendum B, Reference for Causal Factors and Corrective Actions. Another good reference when completing this evaluation, in terms of its comments on human errors that may be made above the worker level, is Chapter 4 here. 

This author believes that for the practice of safety to become recognized as a profession, one of the requirements is to reach agreement on an incident causation model. It is also proposed, as is presented here, that the model must relate to the following truisms— which are repeated here for emphasis. 

Consequently, the application of accident causation models in safety practice is a means of controlling the filtering and organization of data about accident risks and of selecting appropriate measures to improve safety. We present some of the most influential frameworks and models, discussing in detail a human factors approach that highlights the significance of incidents and accidents, respectively. 

This book suggests a new approach to engineering for safety that changes the focus from prevent failures to enforce behavioral safety constraints, from reliability to control. The approach is constructed on an extended model of accident causation that includes more than the traditional models, adding those factors that are increasingly causing accidents today. It allows us to deal with much more complex systems. What is surprising is that the techniques and tools described in part 111 that are built on STAMP and have been applied in practice on extremely complex systems have been easier to use and much more effective than the old ones. 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

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