Taking the risk to think differently about hazard management

Transcription

1 Taking the risk to think differently about hazard management Viji Vijayan Assistant Dean Safety, Health and Emergency Management Past President Biorisk Association of Singapore

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3 Duke-NUS Medical School Established in 2005, first US-style graduate-entry medical school Annual enrolment of over ~ 60 medical students Strong PhD program Over S$320 million in grants 2,000 peer-reviewed journal articles Four wet bench lab based programs Co-located Singapore s largest healthcare group augments translational research

4 What is safety? basic meaning of safety is simply freedom from harm of any nature. This cannot be absolute because there is no such thing. Therefore, organizations and people should find a reasonable or acceptable level of harm they are willing to accept in their respective industries and lives.

5 History of safety In the early days the starting point for safety concerns was always an accident Investigation was performed, cause found they apply the stop-rule Often human factor Replace humans with machines Then machines started to cause more severe accidents

6 History of safety Systems became very complex Human-machine interactions became very critical

7 Complex Systems

8 Complex Systems

9 Complex Systems

10 Complex Systems

11 Sociotechnical System Sociotechnical systems (STS) in organizational development is an approach to complex organizational work design that recognizes the interaction between people and technology in workplaces. The social aspects of people and society and technical aspects of organizational structure and processes. Not material technology, but procedures and related knowledge Sociotechnical refers to the interrelatedness of social and technical aspects of an organization or the society as a whole. Sociotechnical theory therefore is about joint optimization, with a shared emphasis on achievement of both excellence in technical performance and quality in people's work lives. (Wikipedia)

12 Sociotechnical System

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14 Eric Hollnagel The practice of safety is to prevent accidents and yet we spend a lot of time analysing accidents and trying to learn from them. Why do we do this? An unintended but unavoidable consequence of associating safety with things that go wrong is a creeping lack of attention to things that go right. Erik Hollnagel asked this and came up with the concept of safety I and safety II.

15 Safety I- old view Safety is a state where few things go wrong, and that when they do go wrong it is due to failure or malfunctions of the sociotechnical system we work in. Humans, who are viewed as the most unreliable component of this socio-technical system, are considered a liability. In the early days, the starting point for safety concerns was always an accident, especially a major one. When an accident occurred, an investigation was performed and when the investigators found the cause(s) the stop-rule was applied and the search ended. Often, human error was found to be the cause!!

16 Safety II- new view Why does it go right most of the time? Because the same humans who were considered a liability in Safety I are able to anticipate failures and adjust their daily work such that injuries are rare. Safety II is about supporting the people to do their work in the right way such that accidents occur rarely

17 Safety II- new view Duke-NUS: 400 researchers 44 hours a week 915,000 hours a year cases of minor injuries. Things that went right = % Things that go wrong = % per man hour Going Right Going Wrong

18 Safety I and II Safety I Aim for absence negative outcomes Safety management aims to prevent negative outcome by constraining people s behaviour and making them adhere strictly to standards. Safety II Aims for presence of positive outcomes Safety management aims to use the resilience of the system Uses the variability and diversity of the workers and their ability to respond to unexpected situations People DO NOT come to work wanting to cause an accident

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20 How we worked with Zika virus Researches in our Emerging Infectious disease wanted to be the first to publish Has to be done rapidly Not much was known about the virus Initiated by the researchers: Team formed including researchers, safety team, Infectious Diseases Physicians Rapidly discussed the processes Conducted briefings Developed SOPs and RAs Where to grow the virus, where the work can be done, signage, waste disposal Undertaking about pregnancy Provided staff access to ID physicians for counselling Strict oversight of the virus - from import, storage, culturing, disposal, Inventory control

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22 Sociotechnical System

23 Is safety really First? Productivity is first and safety is a very close second On the other hand If you think safety is expensive, then try an accident

24 Efficiency-thoroughness trade-off principle (ETTO) The efficiency thoroughness trade-off principle (or ETTO principle) is the principle that there is a trade-off between efficiency or effectiveness on one hand, and thoroughness (such as safety assurance and human reliability) on the other. In accordance with this principle, demands for productivity tend to reduce thoroughness while demands for safety reduce efficiency.

25 So Safety professional should constantly consult with the actual workers to come up with regulations Following SOPs does not guarantee that accidents will not happen Accidents are often unexpected reactions and the resilience of the system is what prevents it SOPs are critical but with allowances

26 Video