Disclosure slide Disclosure Slide€¦ · • Mateou. Flying in the Face of Criminalization. The...
Transcript of Disclosure slide Disclosure Slide€¦ · • Mateou. Flying in the Face of Criminalization. The...
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(potentiële) belangenverstrengeling Geen
Voor bijeenkomst mogelijk relevante
relaties met bedrijven
• Sponsoring of onderzoeksgeld
• Honorarium of andere (financiële)
vergoeding
• Aandeelhouder
• Andere relatie, namelijk …
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Disclosure slide
Stichting
Trainingen
Infectie
PreventieDisclosure Slide
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Kun je veiligheid wel managen?
Job Brüggen
Safety manager
ATC The Netherlands
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Source: Commercial aviation accidents, 1958 – 2014, A statistical analysis, Airbus
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Source: European Transport Safety Council
Transport statistiek
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US patient safety
•The new Commonwealth Fund study suggests thatthe 1999 Institute of Medicine report, which estimatedthat there are 44,000 to 98,000 deaths annually due tomedical errors, may be the tip of the iceberg in determining the full extent of injuries from medicalerrors. - The Commonwealth Fund, 2002 (Source)
•Based on the IOM's lower estimate of 44,000 deathsannually, medical errors rank as the eighth leadingcause of death in the United States – higher thanmotor vehicle accidents (43,458), breast cancer(42,297), or AIDS (16,516). Agency for healthcareResearch and Quality, 2002 (Source)
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Organisatie/ Hiërarchie
Selectie en
training BeoordelingChecks en
balances
Safety Management
Systems
Verschillen
Sterk
deterministisch
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Overeenkomsten
MENSEN
• Trots
• Professionalisme
• Ego
• Mogelijkheid tot
falen
• Schaamte
• Angst
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Managen van veiligheid
Leiderschap• Inspireer
vanuit de top
Safety Management
• Actief beheersen van risico’s
VeiligheidsCultuur
• Zonder dit werkt niets!
Just Culture • Rock bottom
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Source: Center for Patient Safety, 2016
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Veiligheidscultuur als basis
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Source: www.accelerated-nursing.net, 2016
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Waarom hebben we een just culture
nodig?
• Waar angst regeert, wordt niet geleerd.
• Mensen willen niet goed zijn; ze willen goed
lijken.
• Leren is veiliger dan straffen!
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Just Culture domeinen
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Menselijk gedrag interpreteren
• De ‘lijn’ tussen acceptabel en onacceptabel gedrag bestaat niet.
• Intentie is wat telt, niet de uitkomst.
• Beloon en stimuleer positief
gedrag
• En trouwens… wat doen we met
de manager’s acties?
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www.safetyandjustice.eu
• Over interne just culture zaken
• Uit meerdere domeinen
– Zorg
– Procesindustrie
– Luchtvaart
• Interactief
• Smartphone-ready (Just Culture in your pocket)
• Checklist op firstaid.safetyandjustice.eu
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Achtergrond
• Gebaseerd op JC “models” en theorie– James Reason
– David Marx
– Baines & Simmons
– Hearts & Minds
– Sidney Dekker
• Synthese – Niet te simplistisch
– Niet te ingewikkeld
– Benadruk de positieve kant
– Inclusief de managerial kant
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Navigator
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Andere domeinen
• Indien mogelijk, vergelijk je
situatie met andere
domeinen om van te leren.
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Referenties
• Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon
• Hearts and Minds available at the Energy Institute
• GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment.
• Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results)
• Reason. Managing Risks of Organizational Accidents.Amazon.
• Reason. Human error: models and management.
• Hudson. A new model for a Just and Fair Culture.
• Hudson. Safety Culture – Theory and Practice
• Eurocontrol Skybrary - Link to Just Culture material
• Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment.
• Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for
Accidents
• David Marx. Whack a mole. The price we pay for expecting perfection.
• Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System
• European Commission: EU REG 374/2014
• ICAO Safety Of Information Protection TaskForce
• Eurocontrol Just Culture Policy
• http://www.safetyandjustice.eu
• http://firstaid.safetyandjustice.eu