High-risk Organizations Research Articles

Institutionalizing Patient Safety Culture: A Strategic Priority for Healthcare in India

Fledgling steps in the form of policy measures, surveillance mechanisms and safety initiatives have been taken in the Indian healthcare context to address the increasing evidence base of patient safety events. The paper examines whether structural and processual measures alone would contribute to safer care. The article posits that healthcare organisations in India need to look beyond the structural-procedural efforts and evaluate an essential component of healthcare which serves to bind these efforts; that of safety culture. The paper draws on literature from health services and safety culture research as well as news articles in order to examine adverse incidents in care, safety theories and assess whether structural and procedural efforts would alone contribute to safer care. The review examines the current burden of adverse events in care as well as patient safety initiatives in the Indian context. An emergent strategy comprising policy, regulatory and structural measures has evolved over a period of time to address various facets of patient safety. Global research evidence over the years suggests that such structural-processual measures alone have not been able to address the burden of adverse events in care. Safety culture has emerged as an important concept binding quality and performance measures in most high-risk organizations including healthcare. Institutionalizing safety culture has become a strategic priority in most health care organisations globally. Taking a complex adaptive system perspective, the paper argues that synergizing policy, regulatory and structural-processual measures with safety culture engineering at multiple levels would fetch greater dividends in the Indian patient safety landscape.

Effects of staff bonus systems on safety behaviors

Bonus systems are a common means in trying to motivate employees to perform well. However, there is still disagreement regarding the effects of bonus systems. Some theories even suggest that such systems could cause an increase in risk-behavior. This makes further research regarding bonus systems warranted, especially when applied in high-risk organizations. This study aims to explore potential effects on safety-related behavior associated with bonus systems currently used at Swedish nuclear power plants. Fifteen semi-structured interviews with employees were performed based on an eclectically composed framework from motivational and organizational theories. Results do not indicate any negative effects on safety-related behaviors, but rather that safety behaviors may be promoted insofar as bonus rewards are linked to performance goals concerning safety. Differences in bonus system design appeared to affect behavioral outcomes. The comparative and qualitative approach of this study contributes valuable information by highlighting the types of factors that may serve to stimulate greater incentive for employees to engage in safe behavior.

Speaking up in ad hoc multiteam systems: Individual-level effects of psychological safety, status, and leadership within and across teams

Speaking up in high-risk organizations plays a pivotal role in the mitigation of errors and can make the difference between life and death. To date, speaking up has been studied mostly within teams. However, many high-risk organizations rely on the effective collaboration across teams in ad hoc multiteam systems (MTS). This study widens the scope of research from teams to MTS and empirically compares the mechanisms involved in speaking up within versus across teams in ad hoc MTS-aircrews. In a sample of 1490 aircrew members of a European airline, we found that crewmembers’ individual level perceptions of psychological safety mediated both the relationship between status and speaking up and between perceived leader inclusiveness and speaking up within teams. Across teams, however, psychological safety and leader inclusiveness—as perceived by pursers in their role as boundary spanners—showed no effect. Instead, it was pursers’ within-team perceptions of psychological safety that mediated between status and speaking up across teams. Teams in ad hoc MTS may thus serve as safe harbours supporting their members also in interactions across team boundaries. Implications of findings for research on MTS and practical recommendations to improve speaking up within and across teams in ad hoc MTS are discussed.

Airports at risk: the impact of information sources on security decisions

Security decisions in high risk organizations such as airports involve obtaining ongoing and frequent information about potential threats. Utilizing questionnaire survey data from a sample of airport employees in European Airports across the continent, we analyzed how both formal and informal sources of security information affect employee’s decisions to comply with the security rules and directives. This led us to trace information network flows to assess its impact on the degree employees making security decisions comply or deviate with the prescribed security rules. The results of the multivariate analysis showed that security information obtained through formal and informal networks differentially determine if employees will comply or not with the rules. Information sources emanating from the informal network tends to encourage employees to be more flexible in their security decisions while formal sources lead them to be more rigid with complying with rules and protocols. These results suggest that alongside the formal administrative structure of airports, there exists a diverse and pervasiveness set of informal communications networks that are a potent factor in determining airport security levels.

Guidelines for peer support in high-risk organizations: An international consensus study using the delphi method

Despite widespread adoption of peer-support programs in organizations around the world whose employees are at high risk of exposure to potentially traumatic incidents, little consensus exists regarding even the most basic concepts and procedures for these programs. In this article, consensus refers to a group decision-making process that seeks not only agreement from most participants, but also resolution of minority objections. The aim of the current study was to develop evidence-informed peer-support guidelines for use in high-risk organizations, designed to enhance consistency around goals and procedures and provide the foundation for a systematic approach to evaluation. From 17 countries, 92 clinicians, researchers, and peer-support practitioners took part in a 3-round web-based Delphi process rating the importance of statements generated from the existing literature. Consensus was achieved for 62 of 77 (81%) statements. Based upon these, 8 key recommendations were developed covering the following areas: (a) goals of peer support, (b) selection of peer supporters, (c) training and accreditation, (d) role of mental health professionals, (e) role of peer supporters, (f) access to peer supporters, (g) looking after peer supporters, and (h) program evaluation. This international consensus may be used as a starting point for the design and implementation of future peer-support programs in high-risk organizations.

Coordination and artifacts in joint activity: the case of tagging in high-risk industries

The social, organizational, and technological complexity of high-risk organizations creates a strong need for coordination. Joint activity in such systems thus relies both on formal coordination and on a set of informal coordinative practices. Coordinated joint activity is documented in this paper from two perspectives: the development of coordinative practices to overcome the limitations of formal coordination, and the use of artifacts for coordinative purposes. The empirical material is provided by a workplace study undertaken according to theoretical conceptions of situated action and cognition. It was undertaken in the context of a design project that aims at improving the tagout process in a high-risk industry. Findings first describe and analyze situations in which formal coordination turned out to be more of a constraint than a resource for effective action. They then illustrate the role played by artifacts in coordinated activity, focusing on the use of a particular artifact, the tagout tag, in different situations.

Resident Handoffs: Appreciating Them as a Critical Competency

Resident Handoffs: Appreciating Them as a Critical Competency

Surgeons' leadership in the operating room: an observational study

BackgroundThere is widespread recognition in high-risk organizations that leadership is essential for efficient and safe team performance. However, there is limited empiric evidence identifying specific leadership skills and associated behaviors enacted by surgeons during surgery. MethodsObservational data on surgeons' intraoperative leadership behaviors were gathered during surgeries (n = 29) in 3 hospitals. Observations were coded using 7 leadership elements identified from the literature on surgeons' leadership. Surgeries were categorized by complexity using British United Provident Association ratings. ResultsA total of 258 leadership behaviors were observed during more than 63 hours of observation. Surgeons most frequently showed guiding and supporting (33%), communicating and coordinating (20%), and task management behaviors (15%). In many instances the surgeons' leadership was directed to the room rather than to a specific team member. Surgeons engaged in leadership behaviors significantly more frequently during cases of high complexity compared with cases of lower complexity. ConclusionsThis study is the first step in developing an empirically derived taxonomy to identify and classify surgeons' intraoperative leadership behaviors.

Exploring Resiliency Within Schools

Although research has explored the effects of protective factors on fostering resiliency within individuals, the same level of inquiry has not emerged investigating the causes of why high-risk organizations are resilient to serious violent delinquency. One type of organization that seems particular appropriate for research inquiry is the school. Using a sample of 307 school principals from the School Survey on Crime and Safety, this study investigates how protective factors are individually and cumulatively related to resiliency against serious violence within schools. The findings indicate schools may be more reactive than proactive in their efforts to remain resilient. The theoretical and policy implications of these findings are discussed.

Assessing the Effectiveness of Bridge Resource Management Training

Bridge resource management (BRM) is the maritime equivalent of crew resource management (CRM), and has been used in the civilian maritime industry for over a decade. An evaluation of the effectiveness of the U.S. Navy's BRM training was carried out by assessing the attitudes toward, and knowledge of, the human factors that contribute to accidents in high-risk organizations. A comparison was made between surface warfare officers (SWOs) who had and had not attended BRM training. The responses of the SWOs were also compared to CRM-trained U.S. Naval aviators. It was found that BRM training did not have a significant effect on the attitudes and knowledge of SWOs. Further, naval aviators were significantly more knowledgeable, and generally held attitudes toward the human factors that are causal to accidents in high-risk organizations than did SWOs. It was concluded that the Navy's BRM training is not having the impact on knowledge and attitudes that is typical of the CRM training reported in the literature. It is proposed that the main reason for the lack of effectiveness of the BRM program is that the content of the training was not based on a needs assessment carried out within the surface warfare community.

Psychological First Aid Following Trauma: Implementation and Evaluation Framework for High-Risk Organizations

International clinical practice guidelines for the management of psychological trauma recommend Psychological First Aid (PFA) as an early intervention for survivors of potentially traumatic events. These recommendations are consensus-based, and there is little published evidence assessing the effectiveness of PFA. This is not surprising given the nature of the intervention and the complicating factors involved in any evaluation of PFA. There is, nevertheless, an urgent need for stronger evidence evaluating its effectiveness. The current paper posits that the implementation and evaluation of PFA within high risk organizational settings is an ideal place to start. The paper provides a framework for a phasic approach to implementing PFA within such settings and presents a model for evaluating its effectiveness using a logic- or theory-based approach which considers both pre-event and post-event factors. Phases 1 and 2 of the PFA model are pre-event actions, and phases 3 and 4 are post-event actions. It is hoped that by using the Phased PFA model and evaluation method proposed in this paper, future researchers will begin to undertake the important task of building the evidence about the most effective approach to providing PFA in high risk organizational and community disaster settings.

Practical Patient Safety

This book is aimed at hospital clinicians and is intended, as the title suggests, to help them to improve practical patient safety. In fact, most of the advice applies primarily to patient safety in the operating theatre and, as such, is of value to surgeons, anaesthetists, theatre nurses, operating department practitioners and the managers of these services. The book is easy to read and the style is informal, which is appropriate since it is intended to provide practical advice to facilitate safer patient care. Little theoretical material is included; however, the book is well referenced and provides many good examples from both healthcare and other high-risk organisations. The section on the use of surgical safety checklists, unfortunately, does not include the recent WHO checklist that has been validated and approved for national implementation in the NHS. The photographs are all black and white, and consequently some are not clear, which is disappointing. Boxes are used to highlight certain information but, inconsistently, sometimes for an anecdote and sometimes to bring out a key point. The diagrams are clearer and many of the tables are helpful. There is a glossary that initially may appear redundant but includes an explanation of the importance of staff needing to share a common professional language. The appendices contain useful practical tools that could be implemented readily in any hospital in the NHS. In summary this book provides a ready practical guide for theatre staff to make patient care safer.

Establishing a culture of perinatal safety in a community hospital

While unsafe behavior of frontline hospital staff, primarily physicians and nurses, is sometimes the proximal cause of adverse events, the critical importance of system-wide, hospital organizational factors is now being acknowledged(1,2). These organizational factors create the "safety culture" that influences the occurrence of these proximal failures.(3) The concept of safety culture originated in high-reliability organization theory, which was largely developed by a group of social scientists at the University of California at Berkeley who studied high-risk organizations that have achieved very low accident and error rates, for example, aircraft carrier flight decks, nuclear power plants and air-traffic control systems.(4-6) Safety culture refers to the enduring and shared beliefs and practices of organization members regarding the organization's willingness to detect and learn from errors.(7).

Making Firefighters Deployable

Although sociologists have devoted a considerable amount of research to exploring high-risk organizations, they have not yet developed an adequate explanation as to why individuals working within such organizations place themselves in harm’s way and how organizations ensure they remain there. This article addresses this gap by analyzing how the United States Forest Service motivates wildland firefighters to participate in life-threatening activity. Drawing on ethnographic research and content analyses of official documents, it describes the process by which firefighters come to develop a specific disposition towards risk taking, a disposition through which they view firefighting as an activity void of danger, and how this disposition maintains its shape, and even grows stronger, after confronting its biggest challenge: the death of a firefighter.

Safety in Surgery: Is Selection the Missing Link?

Health care providers comprise an example of a "high risk organization." Safety failings within these organizations have the potential to cause significant public harm. Significant safety improvements in other high risk organizations such as the aviation industry have led to the concept of a high reliability organization (HRO)--a high risk organization that has enjoyed a prolonged safety record. A strong organizational culture is common to all successful HROs, encompassing powerful systems of selection and training. Aircrew selection processes provide a good example of this and are examined in detail in this article using the Royal Air Force process as an example. If the lessons of successful HROs are to be applied to health care organizations, candidate selection to specialties such as surgery must become more objective and robust. Other HROs can provide valuable lessons in how this may be approached.

Practical Patient Safety

Following recent high profile cases of surgical error in the UK and USA, patient safety has become a key issue in healthcare, now placed at heart of junior doctor's training. Errors made by doctors are very similar to those made in other high risk organisations, such as aviation, nuclear and petrochemical industries. Practical Patient Safety aims to demonstrate how core principles of safety from these industries can be applied in surgical and medical practice, in particular through training for health care professionals and healthcare managers.

Are hospitals becoming high reliability organizations?

High Reliability Organizations (HROs) are complex systems in which many accidents and adverse events that could occur within those systems or at the interfaces with other systems are actually avoided or prevented. Many organizations in high-risk industries have successfully implemented HRO approaches. In recent years, initiatives have been undertaken aimed at transforming hospitals into HROs. Actually, despite some improvements, these initiatives have not shown the expected results. In this paper, we discuss the possible reasons for such outcomes. We will show that, when compared with traditional HROs, hospitals are undoubtedly high-risk organizations, but have specificities and experience systemic socio-organizational barriers that make them difficult to transform into HROs.

Three Competing Paradigms: Vertical and Horizontal Integration of Safety Culture Research

Many researches have been generated on the safety culture in high-risk organizations. Despite the number of studies, however, there is a lack of good models that incorporate different theories and methods of safety culture.This research presents an integrated model to explain safety culture and to confirm the model by empirical analysis. This paper consists of two parts: First, after reviewing the existing researches on the safety culture, we propose an integrated model of safety culture that includes, vertically, three competing paradigms to explain safety culture - (a) risk perception paradigm, (b) managerialism and (c) organizational culturalism - and, horizontally, designed causal paths that include deep, mediate and outcome variables. Then we discuss the strength and weakness of each competing paradigm. Second, by using survey data comprising the responses of 862 employees at nuclear power stations in Korea, we test the causal paths and integrated models of three competing paradigmsWe empirically confirm the validity of the integrated model, which includes, vertically, theoretical paradigms and, horizontally, causal paths. This integrated model could contribute to establishing a more balanced scheme of safety culture at risky organizations.

What Are the Critical Success Factors for Team Training in Health Care?

Ineffective communication among medical teams is a leading cause of preventable patient harm throughout the health care system. A growing body of literature indicates that medical teamwork improves the quality, safety, and cost-effectiveness of health care delivery, and expectations for teamwork in health care have increased. Yet few health care professions' curricula include teamwork training, and few medical practices integrate teamwork principles. Because of this knowledge gap, growing numbers of health care systems are requiring staff to participate in formal teamwork training programs. Seven evidence-based, practical, systematic success factors for preparing, implementing, and sustaining a team training and performance improvement initiative were identified. Each success factor is accompanied by tips for deployment and a real-world example of application. (1) Align team training objectives and safety aims with organizational goals, (2) provide organizational support for the team training initiative, (3) get frontline care leaders on board, (4) prepare the environment and trainees for team training, (5) determine required resources and time commitment and ensure their availability, (6) facilitate application of trained teamwork skills on the job; and (7) measure the effectiveness of the team training program. Although decades of research in other high-risk organizations have clearly demonstrated that properly designed team training programs can improve team performance, success is highly dependent on organizational factors such as leadership support, learning climate, and commitment to data-driven change. Before engaging in a teamwork training initiative, health care organizations should have a clear understanding of these factors and the strategies for their establishment.

Coordination in high-risk organizations: the need for flexible routines

In this article, we link the literatures on organizational routines and the management of uncertainties in order to establish the concept of flexible routines. Supported by flexible rules, this type of routine is argued to help achieve the right balance between standardization and flexibility, thus enabling resilience through loose coupling in high-risk organizations. The operationalization of the concept of flexible routine can help strategic decision-making regarding the design of high-risk systems as well as operational decision-making in the course of handling complex work processes. To underpin these arguments, findings from a case study on rules management in a railway organization are presented, where alignment of rules with the amount of uncertainty and actors’ competencies for handling uncertainties were analyzed. Implications for future research on flexible routines are discussed.