Читать книгу Delivering Safety Excellence - Michael M. Williamsen - Страница 16

1 1 RIF Recordable Injury Frequency ([number of injuries requiring medical/doctor treatment] x 200 000) divided by total hours worked.

2 2 The Voluntary Protection Programs (VPP) recognize employers and workers in the private industry and federal agencies who have implemented effective safety and health management systems and maintain injury and illness rates below national Bureau of Labor Statistics averages for their respective industries.

3 3 James Reason (2000) proposed the image of “Swiss cheese” to explain the occurrence of system failures, such as medical mishaps. According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese. These weaknesses are inconsistent, i.e. the holes open and close at random. When by chance all holes are aligned, the hazard reaches a person and causes harm.

4 4 This additional publication material is “Reason, James (1990). The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 327(1241): 475–484”.