Organisational failure: lessons from industry applied in the medical domain

Risk management in the medical domain and medical accidents in particular are receiving growing interest from researchers in industrial engineering and management sciences, psychology, and human factors. Historically there has been little systematic attempt to explore and assess safety for both staff and patients in the medical domain. Conversely, many methods exist to analyse safety and risks in industrial settings, particularly in high-risk industries such as chemical processing, the nuclear power industry, and aviation. To cope with the increasing demand for risk management methods and tools in the medical domain, the possibility of transferring methods and tools initially developed for industrial settings to the medical domain is investigated. This article questions both the benefits and risks of transferring tools from industry to the medical domain. For this purpose, a taxonomy for classifying organisational root causes of safety-related incidents, developed in the steel industry, will be presented. This taxonomy will then be used to classify organisational root causes of both industrial and medical incidents. The article concludes by evaluating the applicability of the taxonomy in the two different domains.

[1]  J. C. Flanagan Psychological Bulletin THE CRITICAL INCIDENT TECHNIQUE , 2022 .

[2]  N. Pidgeon Safety Culture and Risk Management in Organizations , 1991 .

[3]  Van Vuuren Organisational failure: an exploratory study in the steel industry and the medical domain , 1998 .

[4]  J. Porras Stream analysis : a powerful way to diagnose and manage organizational change , 1987 .

[5]  R. F. Griffiths,et al.  HAZOP and HAZAN: Notes on the identification and assessment of hazards : by T.A. Kletz, Institution of Chemical Engineers, Rugby, 1983, ISBN 0-85295-165-5, 81 pages, paperback, £8.00 incl. postage and packing. , 1984 .

[6]  Barry Kirwan,et al.  A Guide to Practical Human Reliability Assessment , 1994 .

[7]  T. W. van der Schaaf PRISMA : a risk management tool based on incident analysis , 1996 .

[8]  A. Glendon,et al.  Human Safety and Risk Management, Second Edition , 2006 .

[9]  Hiromitsu Kumamoto,et al.  Probabilistic Risk Assessment and Management for Engineers and Scientists , 1996 .

[10]  Evert Van de Vliert,et al.  Driedimensionaal kijken naar organisatieproblemen , 1989 .

[11]  H. Schneider Failure mode and effect analysis : FMEA from theory to execution , 1996 .

[12]  D. Norman,et al.  New technology and human error , 1989 .

[13]  J. Battles,et al.  Identification and classification of the causes of events in transfusion medicine , 2008, Transfusion.

[14]  Tjerk W. van der Schaaf,et al.  Near miss reporting in the chemical process industry: An overview , 1995 .

[15]  Jens Rasmussen,et al.  Information Processing and Human-Machine Interaction: An Approach to Cognitive Engineering , 1986 .

[16]  R. Yin Case Study Research: Design and Methods , 1984 .

[17]  T. W. van der Schaaf,et al.  Near Miss Reporting as a Safety Tool , 1991 .

[18]  Barry Kirwan,et al.  Development of a Hazard and Operability-based method for identifying safety management vulnerabilities in high risk systems , 1998 .