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Safety -A Genetic Paradigm

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Abstract

For much of the 19 th and 20 th centuries, the industrial revolution shaped the way people looked at safety. Machines were the marvel of the age, and a major challenge was how to convert a predominantly rural, peasant population, to operate them without breaking them, or themselves; although for much of this time the emphasis was on the former, rather than the latter. The "safety pioneers" (Heinrich et al) were thus developing ways to prevent the inevitable accidents and mistakes that impaired the efficiencies of these installations. Their approach was essentially to try and make the machinery and its operators more reliable and efficient. This culminated in the classic "Quality" initiatives, where efforts were focussed on eliminating any defects (human or mechanical) impairing the theoretical capacity of the processes. This philosophy still survives today in the LEAN, six sigma black belt analyses, much beloved of the manufacturing industries. The Organisation as Machine But after the Second World War, the development of nuclear power, the guaranteed reliability (safety) of which, was critical to its acceptability by communities, meant that a more formal demonstration of its integrity was needed. Thus, Boolean Logic fault and event trees were developed to identify potential defects and failure mechanisms; and then quantified to claim negligible probability of failures due to reliability of components, controls and safety measures. Similar probabilistic "safety" analyses (PSA's or PRA's or QRA's) were employed to demonstrate the same sort of "safety" levels from everything from space shuttles to offshore drilling. But first, the 3 Mile Island and then the Challenger incidents, called into question the claims and reassurances based on the computer printouts. In the Challenger incident, potential defects were identified, such as the low temperature fallibility of the O rings, which were not only reported but raised as real possibilities not probabilities. Nevertheless, the system was operated with tragic consequences. But in NASA, the management had to cope with more than just delivering guaranteed reliability. The realities of political and economic pressures combined to force efficiency thoroughness trade-offs and cost and risk benefit compromises. This brought home the realisation that organisations were not machines and humans were not components and the conventional, current approaches that treated them as such, were no longer adequate, if they ever really were. In the 21 st century, we now realise that they are systems; but more than that, they are complex sociotechnical systems. Thus, they need more understanding about how they behave as a whole, in totality, as systems; not just the detailed behaviour and reliability of individual components. In fact, an organisation is more akin to an organism than a machine. The Organisation as Organism So, what can we learn from a life form, that is evidently complex and an assembly of interacting systems, not just components, such as organs or cells? How do organisms, not just survive, but thrive? The first imperative is survival, and all living things have a detailed set of instructions on how to survive and reproduce. These instructions are encoded as genes, which form readable (by other chemicals) sections of a unique molecule known as DNA. They essentially program the organism to build and
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Safety A Genetic Paradigm
Ralph MacKinnon & David Slater
THE INDUSTRIAL REVOLUTION FROM PEASANT TO PROBLEM
For much of the 19th and 20th centuries, the industrial revolution shaped the way people looked at
safety. Machines were the marvel of the age, and a major challenge was how to convert a
predominantly rural, peasant population, to operate them without breaking them, or themselves;
although for much of this time the emphasis was on the former, rather than the latter.
The “safety pioneers” (Heinrich et al) were thus developing ways to prevent the inevitable accidents
and mistakes that impaired the efficiencies of these installations. Their approach was essentially to try
and make the machinery and its operators more reliable and efficient. This culminated in the classic
“Quality” initiatives, where efforts were focussed on eliminating any defects (human or mechanical)
impairing the theoretical capacity of the processes. This philosophy still survives today in the LEAN, six
sigma black belt analyses, much beloved of the manufacturing industries.
The Organisation as Machine
But after the Second World War, the development of nuclear power, the guaranteed reliability (safety)
of which, was critical to its acceptability by communities, meant that a more formal demonstration of
its integrity was needed. Thus, Boolean Logic fault and event trees were developed to identify
potential defects and failure mechanisms; and then quantified to claim negligible probability of
failures due to reliability of components, controls and safety measures.
Similar probabilistic “safety” analyses (PSA’s or PRA’s or QRA’s) were employed to demonstrate the
same sort of “safety” levels from everything from space shuttles to offshore drilling.
But first, the 3 Mile Island and then the Challenger incidents, called into question the claims and
reassurances based on the computer printouts. In the Challenger incident, potential defects were
identified, such as the low temperature fallibility of the O rings, which were not only reported but
raised as real possibilities not probabilities. Nevertheless, the system was operated with tragic
consequences.
But in NASA, the management had to cope with more than just delivering guaranteed reliability. The
realities of political and economic pressures combined to force efficiency thoroughness trade-offs and
cost and risk benefit compromises. This brought home the realisation that organisations were not
machines and humans were not components and the conventional, current approaches that treated
them as such, were no longer adequate, if they ever really were.
In the 21st century, we now realise that they are systems; but more than that, they are complex
sociotechnical systems. Thus, they need more understanding about how they behave as a whole, in
totality, as systems; not just the detailed behaviour and reliability of individual components. In fact,
an organisation is more akin to an organism than a machine.
The Organisation as Organism
So, what can we learn from a life form, that is evidently complex and an assembly of interacting
systems, not just components, such as organs or cells? How do organisms, not just survive, but thrive?
The first imperative is survival, and all living things have a detailed set of instructions on how to survive
and reproduce. These instructions are encoded as genes, which form readable (by other chemicals)
sections of a unique molecule known as DNA. They essentially program the organism to build and
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operate a viable complex system and are passed on to enable more copies of the organism to be made
to ensure survival of that particular type of organism.
It is essential then, for the survival of the organism and its species, that these DNA blueprints are
faithfully copied and transmitted for future generations. But in the real world, natural variability in
environments and conditions can lead to corrupted DNA code, which if not picked up can be fatal.
In organisational terms, the equivalent would be the corporate repository of IP, Business plans, and
management systems, encoded as procedures and policies. This essentially corporate DNA is
inevitably setting out how ideally things should be done (Work as Imagined). Unfortunately, as well in
organisations, not everything can be written in the book and not everything gets done by the book,
(i.e. Work as actually Done).
Also in organisms, not all operations are carried out exactly as predetermined, programmed by the
DNA. Such variability can cause defects, failures and threaten survival. Thus, organisms have
developed mechanisms to constantly check the accuracy of the DNA strands, that can systematically
look for and repair defects.
Organisations have also often developed (like organisms) their equivalent of gene editing and
correcting mechanisms.1 In the corporate world, there are functions, (The Deming Juran Quality - ISO
9000 process is an example) which perform the same task. One part of this is focussed on Health and
Safety, and its goal is to eliminate faults and hence failures and enforce the (necessarily incomplete?)
“Correct” procedures – the equivalent of the original DNA. The quote below is from a Taproot checklist
aimed at identifying deviations.
Translated into the corporate world this is comparable to the earlier approaches to managing safety
or quality. Eliminate the faults, failures and defects and stick rigidly to the corporate standards by
monitoring, enforcement, training and retraining by the book. These days it is often referred to as
SAFETY I
From survival to success
In organisms, occasionally, stochastically, some variability in conditions can lead to changes in the
code which can offer the organism more than just continued survival, but an actual advantage over
other competing organisms, or increased survival chances in a changing environment. These superior
genes then get incorporated into new DNA and established as the new blueprint for a more successful
organism.
The logical consequences of this are then apparent as the continuous Darwinian evolution of better
and better “adapted” organisms.
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On this model, the SAFETY I mechanism above, can ensure “survival”, but not “success. The Darwinian
development of extra competitiveness or competence where success equals continuous
improvement, gets continually discouraged and “trained out” of the system.
One could say that purely SAFETY I organisations can thus only toe the corporate DNA line and be seen
solely to monitor for deviations and respond with corrections.
To achieve the second step, inheritance mechanisms within organisations need not only to correct
mistakes in transmitting the authentic procedures, but also to incorporate and update them with
those discovered adaptations or variabilities that improve the procedures (SAFETY II).2 Recent studies
of evolutionary biology have indicated that the environment, can impact the inheritance mechanisms
and that DNA is not the only inherited source of information. There is genetic transfer of information
and non-genetic (epigenetic transfer), where the environment can modulate information transferred,
as another route for transfer of adaptations/variants.3 Where WAI can be visualised as DNA, one may
envisage WAD as modulated DNA and other transferred material.2 Such differing inheritance
mechanisms may explain temporal aspects of evolving resilience potentials, those that are rapid and
those more gradual. 2 Thus, a further mechanism that is available to an organisation is to formally seek
out and incorporate improvements to be encoded in DNA or transferred rapidly be other material.
Building on these learned behaviours, further advantage can be obtained by not only consciously
adapting to stay abreast of challenges, but by anticipating and avoiding predicted difficulties and
taking advantage of realised opportunities.
So, the evolving, Darwinian-like (SAFETY II) organisation, adapting to enable superior responses and
hence, performance, can also learn from what goes right, or better still, can compensate for individual
“failures” and has the resilience to anticipate (modify the DNA or transmit by other means) to deal
with these emergent (competitive, novel) survival challenges.
THE OBSERVED PERFORMANCE OF ORGANISATIONS.
Public versus Private sector Organisations
Public sector bodies are archetypal SAFETY I organisations.
They are designed to survive by successfully executing the prescribed (Statutory DNA) procedures to
the letter without deviation. One could say therefore they are not competitive and hence variability
is a bad thing. This includes the NHS and Public sector Healthcare organisations. They can only ever
be as good as the master plan DNA. (Value for money work to a minimum spec not a penny more?)
Private sector organisations, however, are rarely guaranteed survival by statute, or subsidy and hence
inevitably survival is very competitive. Of these organisations, those with no, or limited capacity to
change their procedures (the corporate DNA), will inevitably succumb to “black swan” events – “not
imagined in their philosophies”.
On the other hand, they are free to strive for more than survival, and to realise the need to evolve and
adapt to changing circumstances; to capitalise on their freedom to strive for continuous improvement
This view of organisational behaviour can be seen clearly in the responses of different organisational
models in recent events.
In recent years public sector bodies: police, fire and health in the UK have come under intense scrutiny
following headline events and tragedies where (arguably) their programmed response (trained by the
DNA) was lacking or manifestly incorrect, and they were unable to reflexively adapt their response to
the evolving situations.
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Whereas Big Pharma and academic institutes (competitive environment bodies) have been seen to
rapidly adapt and evolve; for example, during the Covid-19 pandemic by using novel thinking to
produce several vaccines reducing the morbidity/mortality on a global scale (enigma thinking).
Devolved and delegated organisations
Much more interesting, is that despite the challenges with the “management” layers of the NHS, the
emergency response and intensive care unit teams in the COVID-19 pandemic, Manchester Arena and
London Bridge incidents, each having the same sort of training, were able to adapt and cope
successfully
This seems to have been a spontaneous response (and a SAFETY II adaptation), appearing to respond
to deeper than the “normal” SAFETY I encoded public sector management procedures. The challenge
we face is to start to discuss, analyse and understand if and how such adaptations can be inherited to
enhance resilience in public sector organisations.
Why just Safety?
The other insight from looking at an organisation as an organism, is that the organism has a single
mechanism which allows learning and anticipation in all aspects of its existence. The “code-words”
and instructions can be grouped into separate chapters, or chromosomes, but the basic processes are
the same for each chapter.
So, another insight could be that in most organisations, there are separate but similar procedures and
functions that concentrate on improving performance in different areas, such as Productivity, Quality,
Safety and Reliability. But, as they are all examples of the inheritance process, there is inevitably some
duplication, competition and friction if each of these is considered a silo.
Applying a common approach across all these areas, (as complementary, cooperating, chromosomes)
then would seem to offer real benefits. Hollnagel has recently proposed such an approach Synesis,
4 which could again follow naturally from considering the implications of a genetic paradigm.
CONCLUSIONS
Far from being new revolutionary thinking about Safety, the concentration on learning from
experience and applying the insights gained to improve what goes right as well as correcting what
goes wrong, is embedded in our DNA. Now we have got over our 19th century preoccupation with
marvellous machines, we can embrace the full potential of systems thinking. To appreciate the need
for utilising the advantages of integrating the human, physical and cyber components into not just
safer, more efficient and resilient systems, but with a capacity to evolve and continually improve.
REFERENCES
1. Pukk K, Aron DC. The DNA damage response and patient safety: engaging our molecular biology-
oriented colleagues. International journal for quality in health care. 2005;17(4):363-367.
2. MacKinnon R. From in-situ simulation to beyond. PhD thesis submitted for publication, Karolinska
Institutet, Stockholm; 2021.
3. Müller GB. Why an extended evolutionary synthesis is necessary. Interface focus.
2017;7(5):20170015-20170015. doi:10.1098/rsfs.2017.0015
4. Hollnagel, E. (2020). Synesis: The unification of productivity, quality, safety and reliability.
Abingdon, Oxon, UK: Routledge.
ResearchGate has not been able to resolve any citations for this publication.
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Since the last major theoretical integration in evolutionary biology—the modern synthesis (MS) of the 1940s—the biosciences have made significant advances. The rise of molecular biology and evolutionary developmental biology, the recognition of ecological development, niche construction and multiple inheritance systems, the ‘-omics’ revolution and the science of systems biology, among other developments, have provided a wealth of new knowledge about the factors responsible for evolutionary change. Some of these results are in agreement with the standard theory and others reveal different properties of the evolutionary process. A renewed and extended theoretical synthesis, advocated by several authors in this issue, aims to unite pertinent concepts that emerge from the novel fields with elements of the standard theory. The resulting theoretical framework differs from the latter in its core logic and predictive capacities. Whereas the MS theory and its various amendments concentrate on genetic and adaptive variation in populations, the extended framework emphasizes the role of constructive processes, ecological interactions and systems dynamics in the evolution of organismal complexity as well as its social and cultural conditions. Single-level and unilinear causation is replaced by multilevel and reciprocal causation. Among other consequences, the extended framework overcomes many of the limitations of traditional gene-centric explanation and entails a revised understanding of the role of natural selection in the evolutionary process. All these features stimulate research into new areas of evolutionary biology.
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The imperative to improve patient safety is clear. Biomedical scientists, who account for a large proportion of medical school faculty, and clinicians tend to speak different languages. Biological systems are remarkable for their high robustness, flexibility, and efficiency. Biomedical scientists possess a profound understanding of the complex mechanisms that govern organisms. Their insights may inform the design of safer health care systems. We propose a model to assist in bi-directional communication between these disciplines. We use the principles and mechanisms of the DNA damage response to describe the central concepts of safety science and discuss similarities and differences between the systems of DNA repair and organizational approaches to safety in health care. We suggest that such biomedical scientists can and should be engaged in the effort to bring education about patient safety management into the medical school curriculum and to make patient care safer.
From in-situ simulation to beyond. PhD thesis submitted for publication
  • R Mackinnon
MacKinnon R. From in-situ simulation to beyond. PhD thesis submitted for publication, Karolinska Institutet, Stockholm; 2021.