IP? No! Not 'intellectual property' the other one . . .

'Interested Persons'

- also vested in data, information, knowledge, 

who knew how, what, why, when, where ...

individual

|

INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

identity - witness - involvement recall - memory Knowledge - Answers	The (sudden) power of situation, circumstances,  time and place. Events
Society Team - Teamwork Social Justice	Interested Persons Coroner's Court

My source:

Marriage, M. In Search Of Lost Time, FT Magazine. FT Weekend, 22 February 2025, pp.21-27.

https://www.ft.com/content/f94a71ee-0c42-4839-9521-e7866975fa72

There is this thing - 'universal construction'

The problem of bugs in software is an ongoing problem across all IT industries. For application that are safety critical we are still reminded of the risk implications and consequences if bugs are software is not tested and bugs - errors identified and corrected.

Back in the 90s during BA(Joint Hons. Philosophy & Computing) studies, I was introduced to the formal specification language 'Z'. It was designed for definition, and modelling of computer software, working from specification to implementation, as per these images:

https://personalpages.bradley.edu/~young/CS592M120_OLD/handoutZed.pdf

https://personalpages.bradley.edu/~young/CS592M120_OLD/handoutZed.pdf

To be clear I've never worked as part of a software project and my 'tinkering' - Drupal, Pharo, online groups, hosting platform - reveals how the development stack and work processes have developed apace. The challenge is keeping up. Simultaneously, there is the sense of being on the bank of deep water; or, a vertiginous cliff:

A little learning is a dang’rous thing;
Drink deep, or taste not the Pierian spring:
There shallow draughts intoxicate the brain,
And drinking largely sobers us again.
Fir’d at first sight with what the Muse imparts,
In fearless youth we tempt the heights of arts,
While from the bounded level of our mind,
Short views we take, nor see the lengths behind,
But more advanc’d, behold with strange surprise
New, distant scenes of endless science rise! 

Pope. https://interestingliterature.com/2021/09/a-little-learning-is-a-dangerous-thing-meaning-analysis-origin/

 Acknowledging the need for an 'evidence-base' and theoretical underpinning the effort to 'push' Hodges' model forward is ongoing. Maths remains an alien territory to me, but the 'secret garden' is as tantalizing as ever. Over the years I have posted - with much overlap about:

• maths
• relation
• logic

- and more recently:

• isomorphism
• category theory
• and as previously posted - laws of form.

In an effort to get to grips with the above, I'm following various online videos, books and papers. Bartosz Milewski's videos, blog and publications are aimed at programmers, but are very interesting nonetheless. The first video provides an introduction to the motivation and philosophy of category theory. In another, Milewski refers to 'universal construction' on YouTube and in a blog post about 'Function Types'.

The 'universal' figures in healthcare too: universal health access, and universal health coverage appear to over-shadow 'universal health care'. The quality of 'universal' also creeps into assessment. Data gathering is not merely complete, it is comprehensive. It has to be, to contribute not just to a care plan, for one that is (supposedly) person-centred, with risks identified, strengths, weaknesses - needs, history, social network, and much more. The care plan informs and orchestrates the interventions; then evaluation follows. Are we delivering? What is the patient's (client's, carer's) level of satisfaction. Have care stages and actions been completed as per policy (in time!)? (More on this to follow later this year in light of UK mental health/illness news.)

So as I consider (wrestle with...) initial, and terminal objects, sets and categories … I can hopefully, especially with help, extend the number of posts tagged 'universal' here on W2tQ. In this vein, is Hodges' model a universal construction? There may not be a universal truth to reveal, but it will prove a marvellous learning journey.

'Safe space' - which one?

 Individual
  |

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

psychological safety

physical safety

social safety

"NHS staff will be able to speak out about mistakes without fear of reprisal for the first time, thanks to a new investigation unit with "safe space" powers. The Health Services Safety Investigations Body (HSSIB), which was launched last week, has been granted a remit that in effect means any testimony or evidence given to it by doctors, nurses and other staff medical staff will not be handed over to another agency - such as the police, a coroner or the General Medical Council - unless the High Court rules that it must."

Lintern, S. 'Safe space' unit to protect NHS staff reporting medical errors, The Sunday Times, 22nd October 2023, p.11.

"Why models go wrong" BYTE, 1985

Why models go wrong
BYTE

 

"A model can be a physical object: a scale-model of an ancient settlement inferred from archeological evidence, or a physical anthropologist's reconstruction of a skeleton from a few bones and fragments. Most social models, however, are mathematical isomorphisms that specify one-to-one relationships between elements of the model and observable processes or entities. This abstractness gives models great versatility, but it also opens doors to potential problems. You don't need to be a naval architect to see that a model battleship has no bottom, but flaws in an equally defective sociometric model that repeatedly factors a large covariance matrix might escape casual scrutiny." p.151.

My source:
Houston, T.R. 1985. Why models go wrong. BYTE 10(10) : 151-164.

Book: Noise

individual
| 

 INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

noise?
noise?	noise?

Daniel Kahneman, Olivier Sibony, Cass R. Sunstein, Noise: Exclusive Edition (Hardback), HarperCollins Publishers.

Textbook of Patient Safety and Clinical Risk Management

Textbook of Patient Safety
and Clinical Risk Management

About this (open access) book

Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems.

The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. 

This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.

https://link.springer.com/book/10.1007%2F978-3-030-59403-9#about 

My source: HIFA - https://www.hifa.org/

"The complexity of many safety-critical systems makes an a priori analysis of possible system failures and human errors impossible and unreliable. Despite this, it is considered useful to apply this type of healthcare technique to promote reflection among frontline operators before introducing technical or organizational innovation. For example, before introducing a new procedure, it is useful to reflect on the possible, critical aspects of the different phases of the procedure, or, in the case of technological innovation, back-up solutions can be prepared to deal with any malfunctions of the instrument." p.139.

"The role of non-technical skills for patient safety has progressively become more evident through the years and, on this topic, one of the most striking moments of reflection for the healthcare community was Martin Bromiley’s report [10] on the death of his wife in 2005. Fixation errors, absence of  planification, teamwork breakdown, poor communication, unclear leadership, lack of situational awareness, and other non-technical aspects of performance in anesthesiology and critical care medicine can negatively impact patient outcome." p.161.

"In other words, HFE [Human Factors and Eronomics] takes a systems approach that acknowledges the importance of context, emergence and holism in elucidating interactions between various system elements and developing this understanding requires being embedded in the system." p.151.

 W2tQ: safety

 

EHR Individual - Group: Aggregator

People probably look at Hodges' model and see something that is simplistic. There is a great power, however, in the scenarios that the structure of Hodges' model can readily encompass. Not just in the hospital, but across all care contexts.

"Where is the great value promised by the transition to EHR [Electronic Health Record]? Where is the huge surplus from all those lives saved? Without an actor who can find it, and deploy it to shift the doctors into surplus, nothing will happen. 

If the ecosystem* includes just the five traditional players, EHR will remain an academic dream. The answer, then, requires introducing a new player - an aggregator. Because the odds of mistakes are so low, the benefits of EHR are invisible to the individual patient. They become material only when we aggregate outcomes over a large enough number of patients. We need to find an actor whose surplus is affected by patients not as individuals but as a group, and who is able to both capture and distribute this benefit; insurers, health-care systems, and governments all fit the bill. And the larger the group, the larger the surplus." p.130.

*The ecosystem illustrated by Adner is simplified and includes:
Payer/ Insurer, IT Provider, Hospital Administration, Hospital Department, Doctor, Nurse, Patient
(I have added Nurse)

Adner, R. (2012). The Wide Lens: A New Strategy for Innovation. London: Portfolio/Penguin.

"Not a Problem to Solve. It’s a Polarity to Manage"

INDIVIDUAL

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

POPULATION

	See: http://organizationalphysics.com/2017/05/17/its-not-a-problem-to-solve-its-a-polarity-to-manage/

My source:

It’s Not a Problem to Solve. It’s a Polarity to Manage. @LexSisney HT @timkastelle https://t.co/sy4qHoxopJ pic.twitter.com/aNKQRP7hRa

— Mark Storm (@marksstorm) May 21, 2017

Study on attitudes to epistemic uncertainty in safety - Call for participants

From: Eugenio Alberdi, e.alberdi AT CSR.CITY.AC.UK
To: SOCIOTECH AT JISCMAIL.AC.UK
Sent: Tuesday, 17 September 2013, 19:57
Subject: Study on attitudes to epistemic uncertainty in safety - Call for participants

The Centre of Software Reliability and the Department of Psychology at City University London are running a study on reactions to epistemic uncertainty in decision problems about safety.

Perceived errors in such decisions are often debated hotly after the fact, but there is still a need to study how the input to the decision maker can help or hinder correct decisions.

If you are involved in any capacity with probabilistic reasoning about safety and risk, we would be grateful if you take the survey at:

...

This study arises from research project UnCoDe -
(UNcertainty and COnfidence in safety arguments: effect on expert DEcision makers).

All participants will have the opportunity to read the final report from the study and the other project outputs.

Regards,

_eugenio

Dr. Eugenio Alberdi

Research Fellow, Centre for Software Reliability,

City University, London, Northampton Square, London EC1V 0HB