Åsa Ek

Safety checklist compliance and a false sense of safety: new directions for research

In recent years, checklists to improve patient safety have gained considerable support.1–,4 The most well-known checklist introduced for this purpose is probably the WHO surgical safety checklist.5 The WHO checklist consists of three parts: (1) the sign in before anaesthesia, (2) the timeout before incision and (3) the sign out before the patient leaves the operating room. Previous studies show that the WHO checklist reduces both complications from care and the 30-day mortality rate.2 ,3 These results are supported by other studies using similar checklist methodologies.1 ,6 Initially, the evaluation focus was on the effects of checklists using measures such as complications and mortality. Recently, though, researchers have started to pay attention to the actual usage of checklists in practice by investigating compliance.7–,10 The compliance rate reported in these studies could at best be considered as moderate. Rydenfalt et al 8 report a compliance of the timeout part of 54%, despite timeouts being initiated in 96% of the cases studied. In the study by Cullati et al ,7 the mean percentage of validated checklist items in the timeout was 50% and in the sign out 41%. Despite previous studies showing that both complications and 30-day mortality decreased,2 ,3 this raises the question: do safety checklists used with this level of compliance really make practice safer? Could it even be that the lack of compliance actually introduces new risks not present before? In the following viewpoint, we investigate the latter question from a safety science perspective to introduce new perspectives on the usage and implementation of checklists in healthcare and outline suitable directions for future research. ### The checklist as a defence against failure The main idea with checklists such as the WHO surgical safety checklist is to serve as a defence or barrier between …

Efficient and Effective Learning for Safety from Incidents

Learning from incidents is important for improving safety. Many companies spend a great deal of time and money on such learning procedures. The objectives of this paper are to present some early results from a project aimed at revealing weaknesses in the procedures for learning from incidents and to discuss improvements in these procedures, especially in chemical process industries. The empirical base comes from a project assessing organizational learning and the effectiveness of the different steps of the learning cycle for safety and studying relations between safety-specific transformational leadership, safety climate, trust, safety-related behavior and learning from incidents. The results point at common weaknesses in the organizational learning, both in the horizontal learning (geographical spread) and in vertical learning (double-loop learning). Furthermore, the effectiveness in the different steps of the learning cycle is low due to insufficient information in incident reports, very shallow analyses of reports, decisions that focus at solving the problem only at the place where the incident took place, late implementations and weak solutions. Strong correlations with learning from incidents were found for all safety climate variables as well as for safety-related behaviors and trust. The relationships were very strong for trust, safety knowledge, safety participation and safety compliance.

Safety Culture Onboard Ships

A project focusing on identifying and describing maritime risks is being conducted in the heavily trafficked water area of the Sound, situated in northern Europe between Sweden and Denmark. This paper reports of a test of a first version of a questionnaire constructed for measuring safety culture onboard vessels. 48 crew members on a Swedish registered passenger/cargo ship completed and returned the questionnaire. The crew members were able to complete the questionnaire with few unanswered questions. Acceptable homogeneity was obtained for all but one of the nine dimensions of safety culture. Significant differences on several of the safety culture dimensions were found between deck/engine vs catering personnel, men vs women and different age groups, while little differences where found for supervisors vs non-supervisors or people with varying number of years onboard. Such safety culture dimensions need to be studied in relation to reports of accidents and near-misses, to further study the true relevance of safety culture.

From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types

A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reasons Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.

Electrical injury in relation to voltage, "no-let-go" phenomenon, symptoms and perceived safety culture: a survey of Swedish male electricians

PurposeProfessional electricians are highly subjected to electrical injuries. Previous studies describing symptoms after electrical injury have not included people with less severe initial injuries. The purpose of the present study was to describe symptoms at different time points after electrical injury, the impact of “no-let-go” phenomenon and different electrical potential [high voltage (HV) vs. low voltage (LV)], and the safety culture at the workplace.MethodsA retrospective survey was conducted with 523 Swedish electricians. Two questionnaires were issued: the first to identify electricians who had experienced electrical injury and the second to gain information about symptoms and safety culture. Self-reported symptoms were described at different time points following injury. Symptoms for HV and LV accidents were compared. Occurrence or nonoccurrence of “no-let-go” phenomenon was analysed using two-tailed Chi-2. Safety culture was assessed with a validated questionnaire.ResultsNearly all reported having symptoms directly after the injury, mainly paraesthesia and pain. For the first weeks after injury, pain and muscle weakness dominated. The most frequently occurring symptoms at follow-up were pain, muscle weakness and loss of sensation. HV injuries and “no-let go” phenomenon were associated with more sustained symptoms. Deficiencies in the reporting routines were present, as well as shortage of preventive measures.ConclusionThe results indicate that symptoms are reported also long time after an electrical injury and that special attention should be paid to HV injuries and “no-let go” accidents. The workplace routines to reduce the number of work-related electrical injuries for Swedish electricians can be improved.

Organizational Issues and Safety Culture in ATM, Part I - Stability Analysis

The Swedish Air Navigation Services Provider (LFV ANS) are undergoing major organizational changes in order to adapt to changing demands on efficiency and technical development in air traffic control. In these change processes the foundations of the safety work can be affected and changes in the existing safety culture can be introduced. In a joint research project – Human Factors in Air Navigation Services (HUFA) – between the Swedish Civil Aviation Administration and Lund University the focus is on human and organizational factors and safety in air traffic control. The aim of the project is to study safety culture and related organizational issues in order to monitor these during the change processes. Study locations are the two main air traffic control centers and parts of the LFV ANS head office in Sweden. Using questionnaire assessments, three measurement rounds will be conducted during the course of about three years. Studies 1 and 2 are completed, where the first one has given baseline values. After 20 months, study 2 was completed in order to monitor the effect of spontaneously occurring organizational changes. This paper presents results concerning the stability of the investigated organizational climate, leadership style of team managers, psychosocial work environment, and safety culture.

Enablers and Barriers for Implementing Crisis Preparedness on Local and Regional Levels in Sweden

Crisis preparedness planning work can be characterized as complex and challenging being performed in large public organizations requiring communication and cooperation with many people. This paper reports on a bottom-up study investigating the pre-requisites for efficient crisis preparedness work, as well as motivational factors for implementing crisis preparedness decisions, which might be studied and understood in terms of sense-making, communication, and cooperation. As focus was on the crisis preparedness planners’ need to understand their roles, assignments, and authorities in the crisis preparedness planning process, ten semi-structured interviews were conducted with local and regional crisis preparedness planners at a county council in southern Sweden. Enablers and barriers for implementing crisis preparedness were identified and concerned area such as: assuming the role of expert in crisis preparedness planning in one’s organization and understanding what crisis preparedness is about in relation to the organization’s core tasks; power and attaining enough mandate to be able to perform one’s designated work by, e.g. seeking and finding different networks, stakeholders and partners that can legitimate the planner’s work and enable trust and action; communicating demands and benefits of the planners’ tasks realizing that members and working areas in the organization have different needs, cultures, and use different languages; and managing and delivering risk analysis information from the local to the regional level. For a attaining a comprehensive view of enablers and barriers in the crisis preparedness planning processes and implementation, an organizational top-down perspective will also be needed.

Republished: Safety checklist compliance and a false sense of safety: new directions for research.

In recent years, checklists to improve patient safety have gained considerable support.1–,4 The most well-known checklist introduced for this purpose is probably the WHO surgical safety checklist.5 The WHO checklist consists of three parts: (1) the sign in before anaesthesia, (2) the timeout before incision and (3) the sign out before the patient leaves the operating room. Previous studies show that the WHO checklist reduces both complications from care and the 30-day mortality rate.2 ,3 These results are supported by other studies using similar checklist methodologies.1 ,6 Initially, the evaluation focus was on the effects of checklists using measures such as complications and mortality. Recently, though, researchers have started to pay attention to the actual usage of checklists in practice by investigating compliance.7–,10 The compliance rate reported in these studies could at best be considered as moderate. Rydenfalt et al 8 report a compliance of the timeout part of 54%, despite timeouts being initiated in 96% of the cases studied. In the study by Cullati et al ,7 the mean percentage of validated checklist items in the timeout was 50% and in the sign out 41%. Despite previous studies showing that both complications and 30-day mortality decreased,2 ,3 this raises the question: do safety checklists used with this level of compliance really make practice safer? Could it even be that the lack of compliance actually introduces new risks not present before? In the following viewpoint, we investigate the latter question from a safety science perspective to introduce new perspectives on the usage and implementation of checklists in healthcare and outline suitable directions for future research. ### The checklist as a defence against failure The main idea with checklists such as the WHO surgical safety checklist is to serve as a defence or barrier between …

Understanding safety culture by visualization of scenarios - development and evaluation of an interactive prototype

To be able to disseminate knowledge about maritime safety culture and safety management to different actors in the Swedish maritime sector, a preliminary pedagogical concept was developed and evaluated. As a first user group, students at upper secondary maritime schools were chosen and the pedagogical concept was adapted for this group. The concept includes an interactive prototype and a teachers guide and is based on a model for experience-based learning which connects theory and practice by a cyclic approach. The concept was tested in a classroom setting including interaction with the students and a follow-up one week later. A preliminary evaluation of the results shows a very positive response among the students as well as the lecturers. The educational material was successful in immediately creating a relevant discussion about safety culture, and one week later, students could remember many of the safety scenarios included in the pedagogical concept.