Methods & Tools

There are many very useful methods and tools that can be used when applying a “new view” to the field of safety science, especially as it applied to healthcare. Many of these can be easily found in the section “Links”. In this section you will find two tools developed by HSSA, Inc. as well as the Just Culture checklist developed by Sidney Dekker.

Course manual for SPHERE

The course manual which accompanies the SPHERE workshop (SPHERE = Shifting the Paradigm in Healthcare Event Review and Evaluation) is available as a pdf document. This is in the public domain and can be downloaded at no cost. If you want to use or cite any portion of the SPHERE manual please kindly note the source of your citation. It is 70 pages in length in large part because many of the concepts behind this systemic nonlinear approach are relatively new and need some elaboration and exploration. SNAP (Systemic Nonlinear Analysis Protocol) is an integral portion of the manual.

A Few Simple Rules

A Few Simple Rules represents the distillation of important lessons learned from many years of applying the systemic nonlinear approach to understanding healthcare events. These reminders, sometimes in the form of questions, are helpful as you begin to apply the systemic nonlinear analytic approach in your patient safety work.

Just Culture

The influence of professional and organizational cultures on safety-critical situations in complex socio-technical organizations was largely ignored or underestimated until the Three Mile Island nuclear power plant incident in New York in 1979. The disaster at Chernobyl followed by the two NASA incidents (Challenger and Columbia) brought the issue of culture to the forefront and many efforts were made to understand how these factors impacted safety.

One of the early efforts was by James Reason, initially named the Culpability Algorithm, was modified and adopted as the Incident Decision Tree by the NHS in the U.K. Unfortunately most of the models focused significant attention on culpability and built blame into the system, creating serious impediments to the encouragement of staff to report incidents in which they may have been involved. Sidney Dekker has developed an alternative framework (Restorative Just Culture Checklist) which promotes learning and engages, patients, families and the community in the process of understanding the what,why, and how of healthcare adverse events.