When I was growing up as a hospital pharmacist, the talk of patient safety was route cause analysis. When an error happens, find out what went wrong and take action to prevent it from happening again. Classic Swiss cheese model stuff. A lot of the time this ended up in proliferation of protocols and policies to try and ensure everyone knew the right thing to do and make the system safer. That and an overabundance of laminated warning signs blue tacked all over the hospital.
There’s a new approach to safety (not exclusive to healthcare) that shifts the focus away from controlling the system to reduce human error (work as imagined) toward designing systems that make it more likely that humans will be able to perform their work effectively. That’s what this presentation is about.
You can see the presentation here
and the slides here