Understanding and responding when things go wrong: key principles for primary care educators

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a ‘systems approach’ could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a ‘Just Culture’ where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame ‘human error’. System complexity makes reduction into component parts difficult; thus attempting to ‘find-and-fix’ malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a ‘systems approach’ that can increase learning and reduce the damaging effects on morale when ‘human error’ is blamed. This may result in ‘human error’ becoming the starting point of an investigation and not the endpoint

The Blaming Function of Entity Criminal Liability

Application of the doctrine of entity criminal liability, which had only a thin tort-like rationale at inception, now sometimes instantiates a social practice of blaming institutions. Examining that social practice can ameliorate persistent controversy over entity liability\u27s place in the criminal law. An organization\u27s role in its agent\u27s bad act is often evaluated with a moral slant characteristic of judgments of criminality and with inquiry into whether the institution qua institution contributed to the agent\u27s wrong. Legal process, by lending clarity and authority, enhances the communicative impact, in the form of reputational effects, of blaming an institution for a wrong. Reputational effects can flow through to individuals in ways that reduce probability of future wrongdoing by altering individual preferences and forcing reevaluation and reform of institutional arrangements. Blame and utility are closely connected here: the impulse to blame organizations and the beneficial effects of doing so both appear to depend on the degree of institutional influence on the agent. These insights imply that the doctrine should be tailored, unlike present law, to more fully exploit criminal law\u27s expressive capital by selecting cases according to entity blameworthiness. Barriers to describing the phenomenon of organizational influence and culture prevent discovery of a first-best rule of institutional responsibility. A second-best step would be to enhance the existing doctrine\u27s examination of agent mens rea, to impose fault only if the agent acted primarily with the intent to benefit the firm

The accident risk of motorcyclists

This report contains the findings of a study to explore and quantify the interacting influences which determine motorcyclist accident liabilities. It was conducted on behalf of Road Safety Division, Department for Transport. The study first reviewed existing data sources to investigate the trends in motorcycling accidents over the last decade or so. The main part of the study was to carry out a survey of nearly 30,000 current motorcyclists in order to explore the relationship between accident risk and variables such as annual mileage, age, experience, journey type, training, personal characteristics of the riders, and the self-reported behaviours and attitudes of the riders. The numbers of accidents reported by riders within the past 12-months of riding were modelled using generalised linear techniques to take into account factors such as mileage, age, experience, bike size and the conditions prevailing when they rode. Models of rider behaviour were developed using other statistical modelling techniques. These models investigated how attitudes/motivations/perceptions and rider style influence rider behaviour, and how rider behaviour influences the likelihood of accident involvement. The influence of age, sex and experience on attitudes and behaviours, and as direct or indirect influences on accidents were also investigated. Accident risk was also directly influenced by the number of miles ridden in the past 12-months. The report makes a number of recommendations for improving the safety of motorcycle riders

FAIR: Forwarding Accountability for Internet Reputability

This paper presents FAIR, a forwarding accountability mechanism that incentivizes ISPs to apply stricter security policies to their customers. The Autonomous System (AS) of the receiver specifies a traffic profile that the sender AS must adhere to. Transit ASes on the path mark packets. In case of traffic profile violations, the marked packets are used as a proof of misbehavior. FAIR introduces low bandwidth overhead and requires no per-packet and no per-flow state for forwarding. We describe integration with IP and demonstrate a software switch running on commodity hardware that can switch packets at a line rate of 120 Gbps, and can forward 140M minimum-sized packets per second, limited by the hardware I/O subsystem. Moreover, this paper proposes a "suspicious bit" for packet headers - an application that builds on top of FAIR's proofs of misbehavior and flags packets to warn other entities in the network.Comment: 16 pages, 12 figure

Soft Contract Verification

Behavioral software contracts are a widely used mechanism for governing the flow of values between components. However, run-time monitoring and enforcement of contracts imposes significant overhead and delays discovery of faulty components to run-time. To overcome these issues, we present soft contract verification, which aims to statically prove either complete or partial contract correctness of components, written in an untyped, higher-order language with first-class contracts. Our approach uses higher-order symbolic execution, leveraging contracts as a source of symbolic values including unknown behavioral values, and employs an updatable heap of contract invariants to reason about flow-sensitive facts. We prove the symbolic execution soundly approximates the dynamic semantics and that verified programs can't be blamed. The approach is able to analyze first-class contracts, recursive data structures, unknown functions, and control-flow-sensitive refinements of values, which are all idiomatic in dynamic languages. It makes effective use of an off-the-shelf solver to decide problems without heavy encodings. The approach is competitive with a wide range of existing tools---including type systems, flow analyzers, and model checkers---on their own benchmarks.Comment: ICFP '14, September 1-6, 2014, Gothenburg, Swede

Corporate Criminal Liability for Homicide: A Statutory Framework

Since the nineteenth century, judges, legislators, prosecutors, and academics have grappled with how best to accommodate within the criminal law corporations whose conduct causes the death of others. The result of this debate was a gradual legal evolution towards acceptance of corporate criminal liability for homicide. But, as this Note argues, the underlying legal framework for such liability is ill fitting and largely ineffective. Given the public benefit that would accrue from a clearly defined and potent liability scheme, this Note proposes a model criminal statute that would hold corporations directly liable for homicide. The proposed statute draws upon basic precepts of corporate criminal liability, as well as legislative developments in the United Kingdom and the insights of organizational theory. Ultimately, this Note argues that a statutory scheme would allow prosecutions of corporations for homicide to proceed more accurately, effectively, and fairly