Book Corner
We highlight interesting books related to resilience engineering and related topics — from foundational texts to cutting-edge explorations reviewed by members of the RE community.
Still Not Safe: Patient Safety and the Middle-Managing of American Medicine (2019)
Kathleen Sutcliffe (John Hopkins and from the HRO community) co-wrote “Still not Safe” with our dear friend and colleague, Bob Wears (1947 – 2017), published posthumously in Nov 2019.
The term “patient safety” rose to popularity in the late nineties, as the medical community — in particular, physicians working in non-medical and administrative capacities — sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight?
Still Not Safe is the story of the rise of the patient-safety movement — and how an “epidemic” of medical errors was derived from a reality that didn’t support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians’ aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to “rationalize” medical practice — to make a hospital run like a factory.
If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the “epidemic” was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform.
Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system — and provide an opening note for other challenging conversations.
The Oxford Handbook of Expertise (2020)
The Oxford Handbook of Expertise provides a comprehensive picture of the field of Expertise Studies. It offers both traditional and contemporary perspectives, and importantly, a multidiscipline-multimethod view of the science and engineering research on expertise.
Section One deals with frameworks, theories and models for characterising expertise — from neural mechanisms, via the classic expertise approach (dominated by the seminal work of Herbert Simon and Bill Chase), to contemporary macro-cognitive models, situated and distributed approaches, and sociological perspectives.
Section Two covers methods to study, test, analyze and represent expertise: Hierarchical Task Analysis, Incident-based methods, Cognitive Work Analysis, ethnography and video reflexivity.
Section Three delves into domains of expertise: music, sports, healthcare, firefighting, aviation, military, railroad, nuclear, spaceflight, cyber domains, intelligence analysis, law enforcement and business.
Section Four discusses developing, accelerating, and preserving expertise — including ‘team reflection’, ‘cognitive flexibility theory’, the role of mentors and coaches, and a chapter on ‘expertise and resilience’ by Havinga, Bergstrom, Dekker, and Rae.
Section Five contains a timely chapter on the “war” on expertise as waged by five communities that seek to discredit experts. If there is one chapter that everyone in our community should read, it is this one.
At almost 1300 pages this is a true goldmine that provides state of the art reviews as well as foundations for future research.
Exploring Resilience — A Scientific Journey from Practice to Theory
This book explores different approaches for operationalization of resilience across scientific disciplines and system levels, creates a theoretical foundation for a resilience framework, and develops suggestions and inspiration for the research community and practitioners in high-risk industries.
Resilience has become an important topic on the safety research agenda and in organizational practice. Most empirical work on resilience has been descriptive, identifying characteristics of work and organizing activity which allow organizations to cope with unexpected situations. Fewer studies have developed testable models and theories that can be used to support interventions aiming to increase resilience and improve safety.
The book does not advocate for one definition or one field of research when talking about resilience; it does not assume that the use of resilience concepts is necessarily positive for safety. It encourages a broad approach, seeking inspiration across different scientific and practical domains.
By presenting chapters from leading international authors representing different research disciplines and practical fields, the book develops suggestions and inspiration for the research community and for practitioners in high-risk industries.
Foundations of Safety Science — A Century of Understanding Accidents and Disasters
I wrote Foundations of Safety Science foremost for safety practitioners and students. I decided that all could benefit from a more solid grounding in the foundations of the science of safety.
My main concern was a lack of fluency, of literacy, in the ideas, concepts and theories that make up our field — the genealogy, the interconnections, the historical roots from which even today’s models stem. Much safety education — if it discusses models at all — stops at Swiss Cheese (which is thirty years old).
I’ve chosen an episodic approach — dividing the book into time slices. Every chapter is founded on the ideas of a particular era, each roughly a decade from the past century and this one.
How are today’s ‘hearts and minds’ programs linked to a late-19th century definition of human factors as people’s moral and mental deficits? What do Heinrich’s ‘unsafe acts’ from the 1930’s have in common with the Swiss Cheese Model of the early 1990’s? Why was the reinvention of Human Factors in the 1940’s such an important event in the development of safety thinking?
The book concludes with Resilience Engineering as the go-to school of thought today, tracing its roots in the work of Rasmussen, Woods, Hollnagel, Cook and others.
Safety Science Research: Evolution, Challenges and New Directions (2020)
Safety Science Research: Evolution, Challenges and New Directions combines the insights of two generations of writers who are for the first time put together.
Our understanding of safety depends on the way research traditions developed in the 1980s and 1990s. These traditions are rooted in networks of researchers and their backgrounds — psychology, cognitive psychology, social-psychology, management, sociology and political science.
Concepts such as safety culture, high-reliability organisation, resilience engineering or safety regulation are some of the most visible products of these research traditions’ developments.
The book wishes to explore ideas within, across and beyond such research traditions to offer a broad view of current issues and developments which translate some contemporary empirical, conceptual, practical and critical research in the field at the end of the 2010s.
Working Minds — A Practitioner's Guide to Cognitive Task Analysis
Working Minds: A practitioners’ guide to cognitive task analysis is an important resource for anyone who uses cognitive task analysis methods. Beth Crandall, Gary Klein, and Robert Hoffman have all been involved in exploring strategies for eliciting tacit knowledge, analyzing qualitative data, and representing knowledge since the early days of cognitive task analysis.
Working Minds is a practical guide to studying cognition in real-world contexts and professional practice at work. The authors share specific “how to” guidance based on their own experiences conducting cognitive task analysis.
They cover concept maps, incident-based techniques such as the Critical Decision Method, strategies for experiment-like tasks, and most importantly — analysis and representation of qualitative data. Analyzing qualitative data and creating effective representations tailored to project goals is where the magic occurs in cognitive task analysis.
Whether you are just learning cognitive task analysis or have been using these methods for some time, you will enjoy how Crandall, Klein, and Hoffman reflect on their own experiences and share their insights.
For other opportunities to learn about cognitive task analysis, visit the CTA Institute at https://cta.institute.
Ten Patterns That Explain The Universe (2021)
In his newest book (MIT Press, 2021), a well-known science author presents an implicit argument for the driving forces behind the development and operation of the physical and biological world. He does not explore the cognitive or social spheres, nor does he suggest implications for thinking systems.
Cycling through ten patterns — cosmic background radiation, Minkowski Diagrams, particle patterns, Feynman Diagrams, the periodic table, weather patterns, number lines, evolutionary cladograms, the double-helical structure of DNA, and symmetries — the author introduces readers to a wide range of physical and basic bio-scientific research.
Critically, Clegg fails to distinguish between the underlying patterns themselves and the ways in which we typically visualize or represent them. More knowledgeable readers will quickly bore of the isolated context of each chapter and the little attention paid to making connections among the patterns he explores.
In final assessment: an interesting read, but not to be looked to for insight or thoughtfulness.
Synesis — The Unification of Productivity, Quality, Safety and Reliability
Synesis represents the mutually dependent set of priorities, perspectives, and practices that an organisation needs to carry out its activities as intended.
It shows how to overcome the fragmentation in foci, scope, and time that characterises the dominant change management paradigms. This book is not about productivity or quality or safety or reliability but about all of these together — about why it is necessary to think of them as a whole, and about how this can be done in practice.
Resilience in a Digital Age
In recent years, resilience has become a buzzword as it is cited regarding climate emergency, disaster management, impacts of digital transformation, and the COVID-19 global economic crisis.
But what is resilience? How can we benefit from integrating digital transformation into this framework? And in what areas might it be most relevant? Some of the world’s leading experts in resilience were invited to participate in this book and discuss possible answers to these questions.