Steven Shorrock
@StevenShorrock
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Psychologist & transdisciplinary humanistic, systems & design practitioner. Complexity, work, safety, justice, autism. #ActuallyAutistic CPsychol CErgHF PhD
🏴 🇫🇷 🇪🇺 🐝
Joined September 2010
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Pinned Tweet
New Post: The Wrong Kidney
The post introduces a short fictional film, ‘The Wrong Kidney’, created to help explore the complexities of accidents.
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@booksandwine76
@AlexMorrish
My daughter did something even better...
8y/o: What does ‘greatest’ mean?
Me: Biggest
8: Oh, then I need to change my answer on the last page
Me: Why?
8: I thought it meant favourite or best.
Her rationale: You have more years left to live.
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@EylonALevy
Not knowing how to feed you kids is haunting. Kids with autism and learning disabilities being tortured in state hospitals is haunting. This is the face of someone who has not achieved her ambitions, but will nevertheless love a privileged, comfortable life. It won't haunt anyone
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Chinese couple do seemingly impossible acrobatic ballet after English bloke tries to stick tea spoons to his nose.
#BritainsGotTalent
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@AndrewRosindell
Britain is Back...at the bottom of the G7 growth table!
Blue passports to the rescue!
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Blue Nun is the cockroach of wines. It survives even a wine apocalypse.
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A few concepts to be wary of in system safety:
Human error (as cause)
Causal chains
Root causes
Causes, generally
'Loss of situational awareness'
'Zero accidents'
Violations
Monolithic explanations (e.g. Culture)
Performance targets (all)
Safety incentives
'Hearts and minds'
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HOW COMPLEX SYSTEMS FAIL
Richard I. Cook’s
@ri_cook
classic treatise on the nature of failure, how failure is evaluated, how failure is attributed to proximate cause, and the resulting new understanding of safety. In the 🆕
#HindSightMagazine
Issue 31
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@SteveHiltonx
The establishment literally tried to force this through, on the third attempt. The Eton establishment tried to crow bar this through, inc. Johnson and Rees-Mogg. Stick to American populism, Steve.
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Introducing the Just Culture Manifesto, including 5 commitments
More information on each here:
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And here is the problem. Culture is not a lever. You can't manipulate it. You can't design it. It can be influenced, but it is much easier to influence badly by intervention. Work on the work with the people who do the work and are affected by it. Culture change comes for free.
What’s the single most important influence on patient safety? Not money, not regulation. It is culture.
#ImperialPSTRC2018
inspirational talk by
@didoharding
@ImperialNHS
@NHSImprovement
@NHSEngland
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Grateful today to hear that a tumour I’ve been diagnosed with is benign. Thankful for all the healthcare staff involved at all stages of diagnosis and (when it happens) surgery. So many are less fortunate.
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Incredible skill. Now imagine that a terrible accident resulted from being just a few inches closer. Then how would we evaluate the pilot's performance? Success & disaster can be inches apart but we often don't recognise this, and our judgement of performance is based on outcome.
Pilot flies within inches of mountainside to rescue injured French skier.
I've seen helicopter pilots do amazing things, but this one takes first place.
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Airbus €200,000,000 space contract will move from UK to continent due to Brexit.
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You can't 'empower' someone else. When people say this, what they mean is: "I'm still in power. Make no mistake. But I'm going to give you permission. I'm gonna lift my hand. For a bit. Until you tread on my toes."
It's nonsense.
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Yesterday I clocked up 7 active hours on Teams (and 1 hour recording a video for a Teams meeting I can’t attend today).
Without the travel ‘buffer’, are having more meetings than ever. We think we can skip from one to another as if it were PC work. It’s not and it is too much.
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Anyone who describes Human Factors as "common sense" implies that the interaction of physical, social and engineering sciences, and its application to the design of work, is obvious and straightforward. i.e. They don't understand the foundation, scope, or application.
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‘I tell patients, “I’m an anaesthesia associate. That means I’m going to be anaesthetising you: putting you off to sleep and waking you up. I'll be looking after you.”’
And I’ll say, “I want an anaesthetist please.”
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In most cases, trying to "Change the culture" is futile. Act on the system instead: goals, demand, incentives, constraints, resources, flow.
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Telling people to ‘Stay alert’ is ineffective, psychologically.
It’s like telling drivers to ‘Pay attention’ or telling pilots to ‘Maintain situation awareness’.
People remember specific, concrete behaviours, like:
Stay at home
Wash your hands
Keep 2m apart
Wear a face covering
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Training people to perform safely is essential. But after training >1 million NHS staff, you'd still be left with:
Inadequate staffing
Confusing medicine packaging
Poor rosters
Badly designed equipment
Too many policies & guidelines
Shallow investigation
Stressful jobs & tasks
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Systems Thinking is perhaps the most important subject not taught in schools. And it's more important than many subjects that are routinely taught.
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Every time you see a call for 'culture change', imagine trying to change the assumptions, values, beliefs, and behaviours of one person, then multiply that by the number of people who are part of the 'culture'.
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Root Cause Analysis is:
* Acceptable for simple systems
* Inappropriate for complicated systems
* Ludicrous for complex systems
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This is why you always start with understanding work-as-done, not work-as-imagined. The only ‘Plan’ you should start with is a plan to understand the work, including the people who do it, the tools they use and the contexts they work within.
#ergonomics
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Scottish guidance on drink driving in 1972. 😂 🏴
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How (not) to make ‘hot tea’ (what other kind is there)?
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Five Truths about Trade-offs
1. Trade-offs occur at all levels of systems. Trade-offs occur in every layer of decisions making, from international and national policy-making to front-line staff. They occur over years and seconds. They are often invisible from afar.
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The Safety Culture Discussion Cards Edition 2 is out now, for printing (e.g., A6) or screen use.
They can be used in any sector and staff role, and are based on an approach used in over 30 countries.
Free to use. Soon available in >10 languages.
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Safety is nearly never the highest priority, whether patient safety, process safety, occupational safety. We must stop saying that it is, bring out to the open the real day to day pressures, which create priorities, which compete and conflict. Then act on those goal conflicts.
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Last year I bought this book. Like Danny, I had PTSD in my teens and 20s and really had no idea. It returned in my mid 40, unresolved. I just knew the symptoms. Flashbacks (emotional & visual), fight/flight/freeze, free floating anxiety, depression, nightmares, on edge, tics. 1/
I felt silly and embarrassed and as nervous as hell when I phoned the Samaritans. Like I was making a prank call. I mean what did I have to moan about. No, I said to myself, It was just late at night and I was being silly, letting my imagination run away from me like it often did
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Twenty five years ago, I embarked on a career in Human Factors/Ergonomics (HF/E). Below I reflect on what I learned since graduating and have found to be most important to practice in the design and improvement of work.
Full post:
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The Ironies of ‘Automation’
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Systems exist only in our heads - our [shared] understanding - in the same way that cultures exist only in our heads. What is in and outside of the boundary is something that we assume/negotiate/agree. Problems occur especially when we make assumptions about boundaries.
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The problem with Human Factors in healthcare and industry is:
✖️ not a lack of guidance
✖️ not lack of tools
✖️ not a lack of research
The problem is a lack of suitably qualified and experienced practitioners embedded in organisations.
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An influence diagram concerning incident reporting behaviour, in case of use to anyone
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My Mum would have been 71 today. She died at my age, 45, in Christies Hospital, Manchester. I'll spend the day remembering her, though I wish I had more time and more memories, and the ones I had fade over time. Treasure your Mothers.
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For
#WorldPatientSafetyDay
a few ideas, drawing also on other industries:
1. Evaluate staffing impacts. It's hard to truly improve patient safety when so understaffed. If frontline staff are fully occupied with frontline tasks, they can't properly support patient safety work.
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Human-error-as-cause is a nonsense in complex socio-technical systems
Fake missile attack warning? Human error? Nonsense. It's incompetent design. One wrong click terrorizes the entire state? Why is it possible? I have a book they need to read.
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New post:
Getting a Handle on Three Zones of Performance
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@drleighannjones
@GidMK
Boost just means improve or increase, so if one has a deficiency (eg zinc, vitamin D) then one can boost immunity by supplementation. So technically it’s not true, but it depends on the person. Plenty of research on zinc and vitamin D to back this up.
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The slide deck to my talk today at
#HSJpatientsafety
can be downloaded at The various vignettes that I briefly described, and many more, can be read at and the linked posts
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Zoom-as-Imagined
&
Zoom-as-Done
You do what you can, when you can, with what you’ve got
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Finally got round to printing this.
Accidents & incidents:
obvious internally and
externally, investigated in
depth
#SafetyII
1/
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Tomorrow is Sunday. If not at work, for your mental health, I invite you to join me in not reading stuff concerning
#COVID19
.
Instead:
Read a novel 📚
Listen to music 🎶
Watch a film 📺
Play games ♟🕹
Walk in nature 🌳
Exercise 🏃♂️
Bake cakes 🧁
Phone loved ones 👵
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If you have a healthcare course called "Human Factors... " but is really about team resource management and not HF/E, please consider renaming it. It is like calling a one day course on healthy eating "Dietetics", and gives the illusion that HF/E is 'done'... It really isn't.
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Flight attendant: Is there a doctor on this flight?
Dad: *nudging me* that should've been you
Me: Not now Dad
Dad: Not asking for a human factors doctor to help, are they?
Me: Dad, there's a medical emergency happening right now
Dad: Let's see if they need you after we crash
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Obliterate Your PTSD:
-Stop having flashbacks
-Avoid nightmares
-Don’t freeze or try to escape
-Ignore triggers
-Eat whole grains
-Try lavender oil
-Go on holiday
-Think how lucky you are that you’re still alive
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A major problem in society is that so many people just don’t understand risk management and harm reduction. Absolutist, all-or-nothing, never/zero, black and white, thinking is deceptively simple but - in most cases - counterproductive.
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Naive, nonsensical, ill informed.
‘Human error’ is not:
1. a category of behaviour
2. a binary to be contrasted against equipment
3. a cause
‘Human error’ is:
1. hard to define unambiguously a priori
2. inextricably linked to context
3. a zombie concept
Guess which of the below is a more frequent cause of accidents during downtime. Check the answer in our whitepaper:
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On hierarchy... it exists. Don’t deny it. Don’t try to hide or obfuscate it. Everyone knows it’s there, and it’s often there for good reasons. Just try to mitigate its unwanted effects.
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@MattHancock
"Lynn, take a photo of me looking pensive to distract people from my failing career"
@AccidentalP
#AccidentalPartridge
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Here are the five
@icao
Human Performance Principles
The
@icao
Manual on Human Performance (Doc 10151) is out now.
It’s aimed at regulators but Part 1 and much of Part 2 is widely applicable, covering systems thinking, design thinking, and human performance principles, then going onto safety regulation implications.
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Why I didn't put my hand up when
@Kevin_Fong
asked us if commercial aviation was safest form of transport. Very much depends on your metric. Question nobody ask is, how do bus drivers keep people so safe?
#HSJPatientSafety
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@shell_ki
A female runner friend says this happens pretty much every time she runs in different parts of (mostly southern) England (many, many times) but never yet in Scotland (having also run many, many times).
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A few concepts for the curious in system safety:
Interaction
Local rationality
Trade-offs & compromises
Patterns
Work-as-imagined, -prescribed, -done, -disclosed
Adaptation & adjustment
Drift
First & second stories
Field expertise
Emergence
Equivalence
A few concepts to be wary of in system safety:
Human error (as cause)
Causal chains
Root causes
Causes, generally
'Loss of situational awareness'
'Zero accidents'
Violations
Monolithic explanations (e.g. Culture)
Performance targets (all)
Safety incentives
'Hearts and minds'
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Human Factors/Ergonomics, as an applied design science, ALWAYS starts with understanding the system (people, activities, context, tools). It NEVER starts with a predefined tool, course, process, artefact.
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Panic buying of soap is a Tragedy of the Commons - counterproductive individualism & short-termism. If others can’t wash their hands,
#coronavirus
doesn’t care that you’ve got two dozen bars of soap in the garage. You’re more at risk. Give them to others.
#COVID2019
#coronavirus
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Here is a video tutorial on Influence Diagrams, in case it is useful to anyone. It includes a gradual build of an influence diagram on incident reporting behaviour, including influences on capability, opportunity and motivation to report
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There are no Safety-II professionals, but there are professionals who look beyond accidents and incidents and take a broader perspective on the work, and think about systems more holistically. A shift in perspective, but one that is severely challenged by regulatory demands.
The safety II professional is part of what makes the organisation successful; effectively adapting to emerging situations and overcoming challenges.
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The best comparison for a hospital is a really good hospital, not a plane, factory, or nuclear power plant. There are, however, good & bad safety management practices in all industries, and disciplines such as HF/E, psychology, design, ethnography & sociology that can help.
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Well done
@Google
engineers getting services back online after the outage. The behind the scenes action will be impossible to imagine for almost everybody.
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Systems degrade in unpredicted ways such that the system-as-found is not as-imagined.
One thing I won’t ever do again is build a snow dalek. I did that when we lived at our old house as the kids were into Dr Who. I learnt that when snowdaleks start to melt they upset the neighbours
#snowman
#snowdalek
#drwho
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In memory of a great man. His legacy and love will never be forgotton.
HOW COMPLEX SYSTEMS FAIL
Richard I. Cook’s
@ri_cook
classic treatise on the nature of failure, how failure is evaluated, how failure is attributed to proximate cause, and the resulting new understanding of safety. In the 🆕
#HindSightMagazine
Issue 31
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2018 was a tumultuous year for me, where I re-experienced PTSD, and some very dark moments. I got myself out of it through talking to friends and writing poetry. I am in a completely different place now. If you're struggling, don't suffer in silence. Talk. Write. Walk. Create.
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Expertise is intimately tied to artefacts and context. Change those, and a person may no longer be an expert. Expertise therefore functions as something we do, more than something we have. So we should consider expertise-in-the-world and not expertise-in-the-head.
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Well, I decided to publish it. If feels like riskiest article I’ve ever written.
Post-Traumatic Stress (Disorder) - the bull in the china shop.
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You know what France did when people started gathering on beaches (in far fewer numbers, in May, with death rates lower than UK in late June)?
They closed them.
And fines were issued.
You can’t rely on individual ‘common sense’ to ensure physical distancing in this context.
Bournemouth Beach Today:
Let’s not forget the pandemic is far from over.
Rules may be relaxing but restrictions remain in place for a reason.
If they are ignored and the R value rises then tougher lockdown rules will return. Let’s stay alert to the dangers of COVID-19.
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@jbfunk
@NathanJRobinson
@SamWangPhD
Whether one is a socialist or a neolibertarian, does it change the facts? No, it’s irrelevant, except as a device to deny history.
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"Human factors" is not a set of negative factors about humans. It's a discipline focused on human-(rest-of-)system interaction design.
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@rob_england
I don’t believe in root causes (obv) but if I were to pick one at the centre of so many problems - including accidents - it would be pressure.
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So I sent an Eid greeting card to a neighbour. Later this feast arrived:
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The
#DrPhilipLee
@gmcuk
debacle shows how being a member of a professional association can mean that you can’t express yourself as a human being - lawfully - in a way that others can. The defined boundaries for expression diminish citizenship and personhood.
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Targets don't work. They are not magic. They don't increase capacity or improve flow. To do that you have to work on the work and the system conditions.
UK A&E 4hr wait trends. Seasonal variations aside, England and Wales settled into new, higher levels, over the last few years. No country hitting targets.
@NuffieldTrust
@JessieSMorris
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12y/o: When people say “everything will be alright in the end”, it’s very misleading. It makes people think it’s a matter of time instead of a matter of work.
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Imagine writing this at 16...
Wigan has produced another class band in
@TheLathums
(buy the if you like it and you can)
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Yesterday was a normal day where something big happened. I uttered the letters “PTSD” to my GP.
I didn’t go in for that. I went in for achilles tendinitis. I never intended to mention anything else. It was sort of a door handle moment. 1/
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@MattHancock
Don't forget the basics. Staffing. Basic equipment. Capacity. Facilities. Treatment of the most vulnerable in social care facilities. Don't let tech dazzle and gloss over the fundamentals.
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Rhetoric about ‘safety first’ always collides with reality when you see no CEOs at safety conferences.
#HSJPatientSafety
#SafetyFourth
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You can’t “provide” or “assure”psychological safety. It’s a feeling which is highly personal, emerging from the interpersonal. One may feel “safe” and not be safe, or feel “unsafe” with imagined threats. It risks becoming another rainbow chasing exercise.
#HSJPatientSafety
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Human Factors ≠ Training
Human Factors ≠ Teamwork
Human Factors ≠ TRM
Human Factors = Work Design
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So-called ‘soft skills’ are the hardest to learn, and the term denigrates what matters.
They’re really ‘humanistic ways of being’, rooted in humanistic values
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There is no 'root cause'. There are no 'root causes'. Causes in social/sociotechnical systems are social constructions, not objective truths
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You can never ‘understand’ past work-as-done’: you’ll never fully understand what happened in the past.
You can only *approach* an understanding, via the combination of multiple proxies for work-as-done, combined with willingness, curiosity and humility.
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Work Design
➡️Understand work-as-done
➡️Involve others in work-as-imagined
➡️Co-design prototype work-as-prescribed
➡️Implement in WAD
➡️Check against WAI & WAP
➡️Iterate until
#WAIWAD
gap acceptable
➡️Monitor relationships between WAD, WAI and WAP
➡️Repeat
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Quality and safety in the time of Coronavirus: design better, learn faster | OK...but:
Human Factors ≠ Teamwork
5 whys is very outdated
Fishbone is very outdated
Remember PDSA should only start after Study (better S-P-D)
More systems thinking needed.
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