Post-incident review meetings have much more going on than most people are aware of.
New #paper from Hutchinson, Dekker, Rae: How audits fail according to incident investigations: a counterfactual logic analysis
https://aiche.onlinelibrary.wiley.com/doi/10.1002/prs.12579
They use the counterfactual reasoning from incident investigations criticizing audis, and used that to extract what the investigators think auditing should do, and figure out how audits fall short of expectation.
Notes at https://ferd.ca/notes/paper-how-audits-fail-according-to-incident-investigations.html & https://cohost.org/mononcqc/post/4435633-paper-how-audits-fa
This week's #paper is Sidney Dekker's "The psychology of incident investigations"
Which covers 4 motives to incident investigations: epistemological, preventative, moral, and existential (what happened, how to prevent it, which boundaries were transgressed, what's the meaning of the suffering?) and how they all fit together (or don't).
Notes at https://ferd.ca/notes/paper-the-psychology-of-incident-investigations.html & https://cohost.org/mononcqc/post/2551362-paper-the-psycholog
Cool #paper for this week, Ben Lupton and Richard Warren's "Managing Without Blame? Insights from the Philosophy of Blame" at https://link.springer.com/article/10.1007/s10551-016-3276-6
They look at no-blame approaches, then contrast them with at least 4 broad philosophical conceptualizations of blame, and then try to suggest a better alternative to blamelessness, which builds upon more careful blame within communities of practice.
Notes at https://ferd.ca/notes/paper-managing-without-blame.html & https://cohost.org/mononcqc/post/2256727-paper-managing-with
This article explores the concept of blame in organizations. Existing work suggests that ‘no-blame’ approaches (or cultures) may be conducive to organizational learning and may foster innovation. However, both the apparently strong public appetite for blaming, and research into no-blame approaches, suggest that wider application of ‘no-blame’ in organizations may not be straightforward. The article explores the contribution of the rich philosophical literature on blame to this debate, and considers the implications of philosophical ideas for the no-blame idea. In doing so, it identifies conceptual and practical issues, sheds light on why the benefits of ‘no-blame’ may be difficult to realize, and offers the basis for an alternative approach. The article also contributes by providing foundations for future research, and identifies some fruitful lines of enquiry.
Dug out my older notes on Gary Klein's Anticipatory Thinking #paper — https://www.researchgate.net/publication/228953044_Anticipatory_Thinking
The paper looks at what is described as "gambling with your attention" with multiple variants: pattern matching, trajectory tracking, and convergence. It then covers problems and blockers to these functioning well, with suggested work-arounds for individuals and organizations.
Notes at https://ferd.ca/notes/paper-anticipatory-thinking.html & https://cohost.org/mononcqc/post/2186632-paper-anticipatory
Found this in an old technology and society book, in a footnote by Madeleine Akrich:
Rich Lafferty
Phil
John Allspaw
Fred Hebert
juno suárez
Clint "SpamapS" Byrum