Rene Amalberti - Academia.edu (original) (raw)
Papers by Rene Amalberti
BMJ Quality & Safety, 2019
BMJ quality & safety, 2015
Safety Science, 2009
... Full-size table. a Sea fishermen who are not in command on board and hold the following degre... more ... Full-size table. a Sea fishermen who are not in command on board and hold the following degrees: Professional Aptitude Certificate (CAP), Professional Study Diploma (BEP), Nautical Initiation Certificate (CIN), Fishing Initiation Certificate (CIP), no training. ...
The International Journal of Aviation Psychology, 2012
Le travail humain, 2002
ABSTRACT L’article présente une recherche sur la contribution d’un individu à la sécurité du coll... more ABSTRACT L’article présente une recherche sur la contribution d’un individu à la sécurité du collectif auquel il appartient. L’étude a été réalisée à la régulation du SAMU. La méthode reposait sur l’observation et l’analyse d’ “ histoires de gestion d’appels de patients ”, recueillies sur une période de deux mois. Le point de vue choisi a toujours été celui d’un observateur neutre situé derrière le même opérateur de l’équipe, volontairement asymétrique pour l’objectif de l’étude. Il favorisait une détection des erreurs commises par l’opérateur observé (à cause de sa proximité), et une analyse fine des actions de sécurité intentées par cet opérateur vis-à-vis du collectif et vice versa. L’analyse a reposé sur les notes d’observation (protocoles verbaux et contextes d’histoires) en mettant en relation les événements de sécurité observés avec le contexte, le type d’activité du collectif, et les modes de contrôle de la situation. Les résultats montrent, à côté d’une activité classique autodirigée vers ses propres erreurs, que l’opérateur observé intervient fréquemment au niveau du collectif pour l’alerter contre un potentiel d’erreur non encore avéré par les faits. La régulation du risque utilise deux logiques différentes : une régulation des erreurs sur le court terme et une régulation préventive sur le moyen terme par des actions de renforcement de la représentation commune de la situation. L’article présente en conclusion un modèle cadre d’analyse de la contribution de l’individu dans la sécurité du collectif, qui ouvre sur une compréhension dynamique et écologique de la gestion sûre de l’activité collective.
Human Factors: The Journal of the Human Factors and Ergonomics Society, 2008
As the world's mo... more As the world's most dangerous profession, sea fishing enables discussion of the concept of resilience and its articulation to the notion of safety in complex systems. In the small, emerging community working on this concept, the prevailing idea to improve safety is that resilience must be reinjected into the know-how of complex systems. Thirty-four male skippers, divided into two groups, took part in an interactive simulation of a fishing campaign. They had to make decisions in situations of trade-off between safety and production goals. From the time they left the harbor, the fishermen never gave up on fishing, even in extreme conditions, and regardless of whether or not the catch was good. Not being suicidal, however, they used multiple expert strategies to reduce risk without giving up on their fishing activity. Systems run by craftspeople are very resilient because they rely on a high level of adaptability, based on the actors' expertise, linked to an exposure to frequent and considerable risk. Each actor is responsible for his or her own safety. The final discussion bears on the question of knowing whether or not it is possible to design a safe system while preserving its craftsmanship and therefore its native resilience. The results of these studies suggest potential adverse effects of classic safety interventions in complex sociotechnical systems either in terms of professional reluctance to accept new recommendations or through the emergence of new sources of risk.
Revue de Chirurgie Orthopédique et Traumatologique, 2011
Revue de chirurgie orthopédique et traumatologique (2011) 97, [348][349][350][351][352][353][354]... more Revue de chirurgie orthopédique et traumatologique (2011) 97, [348][349][350][351][352][353][354][355][356][357][358] PRATIQUE PROFESSIONNELLE Dimensions du risque de la chirurgie orthopédique en activité libérale ଝ
analysis is based on the screening of various socio-technical professions, such as the aviation, ... more analysis is based on the screening of various socio-technical professions, such as the aviation, nuclear power, chemical, and food industries; road transportation; and health care. The benchmark analysis aims to associate specific traits of these industries with their safety performance. We then describe 5 high-level organizational dimensions derived from the general literature on risk and safety (11-13), each of which
BMJ Quality & Safety, 2011
Innovation is often regarded as uniformly positive. This paper shows that the role of innovation ... more Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed.
SAE Technical Paper Series, 1999
Revue d'Épidémiologie et de Santé Publique, 2008
Safety Science, 2009
macro ergonomics 21 2 2 a b s t r a c t 23 Context: Professional sea fishing is among the world's... more macro ergonomics 21 2 2 a b s t r a c t 23 Context: Professional sea fishing is among the world's most variable (non-standardized) and dangerous 24 sectors of activity. Because of this, it provides a remarkable model to study the complex links existing 25 between resilience and safety. Paradoxically, even if the huge risks being run cause many shipwrecks 26 (low safety level), studies show that these sailors avoid an even greater number of accidents thanks to 27 their exceptional skill and know-how (remarkable resilience level). This article examines several ways 28 of improving safety in an activity of this type. 29 Method: Two intervention strategies are tested: (i) a micro-ergonomics strategy offering conduct assis-30 tance guidelines based on accident analyses of the most serious and frequent causes (collisions while 31 fishing); (ii) a macro-ergonomics strategy comparing the safety level of large firms having committed 32 to a Total Quality approach, to that of smaller companies, often privately owned. 33 Result: Neither of the two strategies works out as expected. The micro-ergonomics anti-collision assis-34 tance strategy is misused towards an increase of the fishing objective; the macro-ergonomics strategy 35 is even more surprising: the largest firms suffer from a smaller number of shipwrecks, but a much greater 36 number of work-related injuries; the strategy simply results in a minor shift of the sacrificial decision 37 between performance and safety (loss of men vs. loss of vessels), while maintaining the same priority 38 for financial performance. 39 Discussion: The article submits a simple modeling of the relationship between resilience and safety, and 40 discusses the choice of strategies for safety-improving interventions, taking into account the system's 41 financial performance and the legal pressure to which it is subjected.
La sécurité du patient en médecine générale, 2010
The International Journal of Aviation Psychology, 2012
Safety Science, 2003
For the design of most technical systems a desirable safe field of use is calculated from systems... more For the design of most technical systems a desirable safe field of use is calculated from systems technical constraints, and expectations of human capacities and limitations. Performance incursions outside the safe field are then limited by means of hard-protections, instructions, education, and regulations. However, once in service, the socio-technical conditions of work create conditions for performance to migrate and stabilise outside the expected safe field of use. The stabilisation of migration results from a compromise between global performance improvement, individual additional advantages, and apparent risk control. This paper proposes a double modelling approach to such migrations, first in terms of a cognitive model of the production of migrations, and second in terms of a mathematical safety analysis of severity and consequences. Both approaches lead to the emergence of methodologies in order to take BTCU into account during design. Conclusions highlight the impossibility of avoiding such in service migrations of use, and advocate for an early consideration of potential migrations in order to improve the robustness of safety analysis techniques. The field example chosen for demonstration is the design and use of a rotary press. # Safety Science 41 www.elsevier.com/locate/ssci 0925-7535/02/$ -see front matter # 2002 Elsevier Science Ltd. All rights reserved. P I I : S 0 9 2 5 -7 5 3 5 ( 0 2 ) 0 0 0 3 7 -1
Quality and Safety in Health Care, 2006
Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to... more Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to eliminate them and reprimand those concerned. However, the situation is not that simple. Firstly, violations paradoxically may be markers of high levels of safety because they need constraints and defences to exist. They may even become more frequent than errors in ultrasafe systems. Secondly, violations have both positive and negative aspects. On the one hand they occur frequently, increase system performance and individual satisfaction, are mostly limited to practices with limited safety consequences, and therefore are often tolerated or even encouraged by the hierarchy. On the other hand, extreme violations can lead to real danger or actual harm. This paper proposes a three phase model derived from Rasmussen’s theory of migration to boundaries to explain the mechanism by which the deviance occurs, stabilizes, regresses, or progresses to harm. The model suggests that violations are un...
L'année psychologique, 2000
... Medium, d3 : Long. Nombre de transitions. Le nombre de transitions (indice de gestion de tâch... more ... Medium, d3 : Long. Nombre de transitions. Le nombre de transitions (indice de gestion de tâches en temps partagé) est sensible à la fois à la vitesse et au délai (fig-7). Vitesse du processus et temps partagé. 653. Fig. 7. Nombre ...
Journal of Risk Research, 2007
In France studies on technological risks began to question errors, failures and vulnerabilities a... more In France studies on technological risks began to question errors, failures and vulnerabilities at the end of the 1970s, focusing mostly on analyzing major accidents as consequences of the increasing complexity of socio-technical systems. During the 1980s and 1990s, research studies carried out in different fields (industrial risks, natural risks, health risks) underlined the importance of organizational factors in system vulnerabilities. Still, the bases of safety policies and safety management remained unchanged, with a strong reliance on rules and procedures. Building on an interdisciplinary reflection carried out at the beginning of the 2000s, this paper calls into question the prevailing approach as regards safety. Identifying the basic assumptions behind safety policies, it is argued that, in light of research advances in various fields of safety studies -and more specifically in cognitive ergonomics -they appear to be basically flawed. In a quite radical manner, a recognition of errors and failures as a part of the usual functioning of socio-technical systems, which are ''naturally'' unstable systems, is called for. As for risk control, it appears to result mainly from the capacity of operators, working groups and organisations for dynamically ''making up'' for errors and failures. These analyses open very stimulating prospects of research. However, the question of their social and political acceptability must be seriously considered.
BMJ Quality & Safety, 2019
BMJ quality & safety, 2015
Safety Science, 2009
... Full-size table. a Sea fishermen who are not in command on board and hold the following degre... more ... Full-size table. a Sea fishermen who are not in command on board and hold the following degrees: Professional Aptitude Certificate (CAP), Professional Study Diploma (BEP), Nautical Initiation Certificate (CIN), Fishing Initiation Certificate (CIP), no training. ...
The International Journal of Aviation Psychology, 2012
Le travail humain, 2002
ABSTRACT L’article présente une recherche sur la contribution d’un individu à la sécurité du coll... more ABSTRACT L’article présente une recherche sur la contribution d’un individu à la sécurité du collectif auquel il appartient. L’étude a été réalisée à la régulation du SAMU. La méthode reposait sur l’observation et l’analyse d’ “ histoires de gestion d’appels de patients ”, recueillies sur une période de deux mois. Le point de vue choisi a toujours été celui d’un observateur neutre situé derrière le même opérateur de l’équipe, volontairement asymétrique pour l’objectif de l’étude. Il favorisait une détection des erreurs commises par l’opérateur observé (à cause de sa proximité), et une analyse fine des actions de sécurité intentées par cet opérateur vis-à-vis du collectif et vice versa. L’analyse a reposé sur les notes d’observation (protocoles verbaux et contextes d’histoires) en mettant en relation les événements de sécurité observés avec le contexte, le type d’activité du collectif, et les modes de contrôle de la situation. Les résultats montrent, à côté d’une activité classique autodirigée vers ses propres erreurs, que l’opérateur observé intervient fréquemment au niveau du collectif pour l’alerter contre un potentiel d’erreur non encore avéré par les faits. La régulation du risque utilise deux logiques différentes : une régulation des erreurs sur le court terme et une régulation préventive sur le moyen terme par des actions de renforcement de la représentation commune de la situation. L’article présente en conclusion un modèle cadre d’analyse de la contribution de l’individu dans la sécurité du collectif, qui ouvre sur une compréhension dynamique et écologique de la gestion sûre de l’activité collective.
Human Factors: The Journal of the Human Factors and Ergonomics Society, 2008
As the world's mo... more As the world's most dangerous profession, sea fishing enables discussion of the concept of resilience and its articulation to the notion of safety in complex systems. In the small, emerging community working on this concept, the prevailing idea to improve safety is that resilience must be reinjected into the know-how of complex systems. Thirty-four male skippers, divided into two groups, took part in an interactive simulation of a fishing campaign. They had to make decisions in situations of trade-off between safety and production goals. From the time they left the harbor, the fishermen never gave up on fishing, even in extreme conditions, and regardless of whether or not the catch was good. Not being suicidal, however, they used multiple expert strategies to reduce risk without giving up on their fishing activity. Systems run by craftspeople are very resilient because they rely on a high level of adaptability, based on the actors' expertise, linked to an exposure to frequent and considerable risk. Each actor is responsible for his or her own safety. The final discussion bears on the question of knowing whether or not it is possible to design a safe system while preserving its craftsmanship and therefore its native resilience. The results of these studies suggest potential adverse effects of classic safety interventions in complex sociotechnical systems either in terms of professional reluctance to accept new recommendations or through the emergence of new sources of risk.
Revue de Chirurgie Orthopédique et Traumatologique, 2011
Revue de chirurgie orthopédique et traumatologique (2011) 97, [348][349][350][351][352][353][354]... more Revue de chirurgie orthopédique et traumatologique (2011) 97, [348][349][350][351][352][353][354][355][356][357][358] PRATIQUE PROFESSIONNELLE Dimensions du risque de la chirurgie orthopédique en activité libérale ଝ
analysis is based on the screening of various socio-technical professions, such as the aviation, ... more analysis is based on the screening of various socio-technical professions, such as the aviation, nuclear power, chemical, and food industries; road transportation; and health care. The benchmark analysis aims to associate specific traits of these industries with their safety performance. We then describe 5 high-level organizational dimensions derived from the general literature on risk and safety (11-13), each of which
BMJ Quality & Safety, 2011
Innovation is often regarded as uniformly positive. This paper shows that the role of innovation ... more Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed.
SAE Technical Paper Series, 1999
Revue d'Épidémiologie et de Santé Publique, 2008
Safety Science, 2009
macro ergonomics 21 2 2 a b s t r a c t 23 Context: Professional sea fishing is among the world's... more macro ergonomics 21 2 2 a b s t r a c t 23 Context: Professional sea fishing is among the world's most variable (non-standardized) and dangerous 24 sectors of activity. Because of this, it provides a remarkable model to study the complex links existing 25 between resilience and safety. Paradoxically, even if the huge risks being run cause many shipwrecks 26 (low safety level), studies show that these sailors avoid an even greater number of accidents thanks to 27 their exceptional skill and know-how (remarkable resilience level). This article examines several ways 28 of improving safety in an activity of this type. 29 Method: Two intervention strategies are tested: (i) a micro-ergonomics strategy offering conduct assis-30 tance guidelines based on accident analyses of the most serious and frequent causes (collisions while 31 fishing); (ii) a macro-ergonomics strategy comparing the safety level of large firms having committed 32 to a Total Quality approach, to that of smaller companies, often privately owned. 33 Result: Neither of the two strategies works out as expected. The micro-ergonomics anti-collision assis-34 tance strategy is misused towards an increase of the fishing objective; the macro-ergonomics strategy 35 is even more surprising: the largest firms suffer from a smaller number of shipwrecks, but a much greater 36 number of work-related injuries; the strategy simply results in a minor shift of the sacrificial decision 37 between performance and safety (loss of men vs. loss of vessels), while maintaining the same priority 38 for financial performance. 39 Discussion: The article submits a simple modeling of the relationship between resilience and safety, and 40 discusses the choice of strategies for safety-improving interventions, taking into account the system's 41 financial performance and the legal pressure to which it is subjected.
La sécurité du patient en médecine générale, 2010
The International Journal of Aviation Psychology, 2012
Safety Science, 2003
For the design of most technical systems a desirable safe field of use is calculated from systems... more For the design of most technical systems a desirable safe field of use is calculated from systems technical constraints, and expectations of human capacities and limitations. Performance incursions outside the safe field are then limited by means of hard-protections, instructions, education, and regulations. However, once in service, the socio-technical conditions of work create conditions for performance to migrate and stabilise outside the expected safe field of use. The stabilisation of migration results from a compromise between global performance improvement, individual additional advantages, and apparent risk control. This paper proposes a double modelling approach to such migrations, first in terms of a cognitive model of the production of migrations, and second in terms of a mathematical safety analysis of severity and consequences. Both approaches lead to the emergence of methodologies in order to take BTCU into account during design. Conclusions highlight the impossibility of avoiding such in service migrations of use, and advocate for an early consideration of potential migrations in order to improve the robustness of safety analysis techniques. The field example chosen for demonstration is the design and use of a rotary press. # Safety Science 41 www.elsevier.com/locate/ssci 0925-7535/02/$ -see front matter # 2002 Elsevier Science Ltd. All rights reserved. P I I : S 0 9 2 5 -7 5 3 5 ( 0 2 ) 0 0 0 3 7 -1
Quality and Safety in Health Care, 2006
Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to... more Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to eliminate them and reprimand those concerned. However, the situation is not that simple. Firstly, violations paradoxically may be markers of high levels of safety because they need constraints and defences to exist. They may even become more frequent than errors in ultrasafe systems. Secondly, violations have both positive and negative aspects. On the one hand they occur frequently, increase system performance and individual satisfaction, are mostly limited to practices with limited safety consequences, and therefore are often tolerated or even encouraged by the hierarchy. On the other hand, extreme violations can lead to real danger or actual harm. This paper proposes a three phase model derived from Rasmussen’s theory of migration to boundaries to explain the mechanism by which the deviance occurs, stabilizes, regresses, or progresses to harm. The model suggests that violations are un...
L'année psychologique, 2000
... Medium, d3 : Long. Nombre de transitions. Le nombre de transitions (indice de gestion de tâch... more ... Medium, d3 : Long. Nombre de transitions. Le nombre de transitions (indice de gestion de tâches en temps partagé) est sensible à la fois à la vitesse et au délai (fig-7). Vitesse du processus et temps partagé. 653. Fig. 7. Nombre ...
Journal of Risk Research, 2007
In France studies on technological risks began to question errors, failures and vulnerabilities a... more In France studies on technological risks began to question errors, failures and vulnerabilities at the end of the 1970s, focusing mostly on analyzing major accidents as consequences of the increasing complexity of socio-technical systems. During the 1980s and 1990s, research studies carried out in different fields (industrial risks, natural risks, health risks) underlined the importance of organizational factors in system vulnerabilities. Still, the bases of safety policies and safety management remained unchanged, with a strong reliance on rules and procedures. Building on an interdisciplinary reflection carried out at the beginning of the 2000s, this paper calls into question the prevailing approach as regards safety. Identifying the basic assumptions behind safety policies, it is argued that, in light of research advances in various fields of safety studies -and more specifically in cognitive ergonomics -they appear to be basically flawed. In a quite radical manner, a recognition of errors and failures as a part of the usual functioning of socio-technical systems, which are ''naturally'' unstable systems, is called for. As for risk control, it appears to result mainly from the capacity of operators, working groups and organisations for dynamically ''making up'' for errors and failures. These analyses open very stimulating prospects of research. However, the question of their social and political acceptability must be seriously considered.