Background: The Functional Resonance Analysis Method (FRAM) analyses discrepancies between written protocols (Work-as-Imagined) and real-world practice (Work-as-Done) in healthcare. Work-as-Done is created based on multiple stakeholders, leading to variability in reported functions. No guidance exists how to manage this variability. This study examines between-stakeholder variation in Work-as-Done and its impact on differences from Work-as-Imagined in FRAM visualisations. Methods: Two FRAM studies were analysed: delirium diagnosis and treatment (1) and perioperative anticoagulant management in two hospitals (2). Heatmaps visualised between-stakeholder variability of reported functions in Work-as-Done. We assessed the impact of including only functions shared by multiple stakeholders on Work-as-Imagined versus Work-as-Done comparisons. Results: In study 1, 23 of 33 functions were shared among at least two stakeholders. In study 2, stakeholders shared 30 of 33 functions in Hospital 1 and 29 of 32 functions in Hospital 2. Including or excluding functions, e.g., only mentioned by one stakeholder, influenced the observed differences between Work-as-Imagined and Work-as-Done. Conclusions: Between-stakeholder variability in both studies influenced differences between Work-as-Imagined and Work-as-Done, which often is the starting point improving the process. Showing between-stakeholder variability in FRAM studies enhances transparency in researcher decision-making. This supports more informed analysis and discussion in process improvement efforts.

Background
Healthcare workers (HCWs) voicing their views (speaking up) is crucial for patient safety and care quality. Yet, this is underused, especially during multidisciplinary team meetings (MDTMs), where diverse professionals collaborate to optimise patient treatment plans. Despite the benefits of open communication, HCWs face barriers such as hierarchical dynamics, time constraints and psychological risks.

Aim
This study examines factors influencing HCWs’ speaking-up behaviours in MDTMs, focusing on motivators, barriers and dynamics across disciplines.

Method
We conducted 21 semistructured interviews with MDTM participants of a gastrointestinal surgery ward, including surgeons, residents, nurses, nursing students, dieticians, ostomy nurses and physical therapists. Data were analysed collaboratively using thematic analysis.

Results
Participants are highly motivated to advocate for patients and provide optimal care. However, barriers impact speaking up during MDTMs. Three major themes were identified: (1) time pressure, (2) perception of goals and roles and (3) familiarity among team members. Structural, relational and contextual factors affect HCWs’ ability to speak up, with nurses and paramedics experiencing more hesitancy than physicians. Lack of preparation time, ambiguous objectives, no formal agenda and unfamiliarity among team members hinder contributions, leading to unbalanced input.

Conclusion
Findings support a systems-based approach to addressing barriers. Interventions should focus on clear goals, reduced time pressures and enhanced team cohesion, rather than placing the responsibility solely on individuals. For instance, adjusting meeting schedules to accommodate diverse availability improves participation across disciplines. Strengthening familiarity among team members fosters trust and lowers the perceived risks of speaking up, ensuring more balanced contributions during MDTMs.

Current treatment approaches for Autism spectrum disorder (ASD) primarily focus on symptom management rather than addressing underlying dysfunctions. The ketogenic diet (KD), a high-fat, low-carbohydrate diet inducing nutritional ketosis, has shown promise in treating epilepsy and may offer therapeutic benefits for ASD by modulating metabolic and neuroprotective pathways. This review examined the potential impact of KD on underlying mechanisms in ASD. While evidence from human studies on underlying mechanisms is limited, animal research has shown a large overlap of mechanisms modulated by KD and dysfunctions in ASD. As such, targeting multiple disrupted pathways at once, KD presents a potential multifaceted treatment approach for ASD. However, more evidence from human studies is needed on the effectiveness of KD in the modulation of underlying dysfunctions in ASD. Additionally, precision medicine approaches could help identify individuals who would benefit most from the intervention, potentially extending its use to other psychiatric conditions with similar metabolic patterns. Consequently, KD interventions might show the potential to induce a drastic paradigm shift in understanding and treating ASD.

Background
Speaking up among healthcare professionals plays an essential role in improving patient safety and quality of care, yet it remains complex and multifaceted behaviour. Despite awareness of potential risks and adverse outcomes for patients, professionals often hesitate to voice concerns due to various influencing factors. This complexity has encouraged research into the determinants of speaking-up behaviour in hospital settings. This review synthesises these factors into a multi-layered framework. It aims to provide a more comprehensive perspective on the influencing factors, which provides guidance for interventions aimed at fostering environments contributing to speaking up in hospitals.

Methods
A systematic review was conducted in November 2024, searching databases: PubMed, Scopus and Web of Science. Following PRISMA guidelines and the three stages for thematic synthesis, we developed the classification of influencing factors. Out of 1,735 articles identified articles, 413 duplicates were removed, 1,322 titles and abstracts were screened, and 152 full texts (plus six additional articles) were assessed. Ultimately, 45 articles met the inclusion criteria.

Results
The review categorised influencing factors into four categories: individual (29 articles, 64%), relational (21 articles, 47%), contextual (19 articles, 42%), and organisational (26 articles, 58%). These categories encompass motivating, hindering and trade-off factors affecting speaking up among healthcare professionals in hospitals.

Conclusions
The multi-layered framework highlights the dynamic interplay of factors influencing speaking up among healthcare professionals. A systems approach is essential for identifying barriers and enablers and designing effective speaking up interventions. This framework serves as a foundation for more focused research and practical guidance, enabling healthcare leaders to address barriers across all categories. By fostering environments that support open communication, organisations can enhance patient safety and quality of care.

Objectives The goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports. Methods Based on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied. Results In the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement. Conclusion The RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety.

In the Netherlands, approximately 2.300 workers have a serious reportable accident at work every year, of which around 60 are fatal (Inspectie SZW, 2020; Bellamy et al., 2014). Safety practitioners employ many methods to improve occupational safety for workers within their companies. Interventions might, for example, be aimed at improving companies’ overall ‘safety culture’, at the introduction of a safety management system (e.g. Robson et al., 2007), or at improving the compliance of workers to specific safety rules (e.g. Peuscher and Groeneweg 2012; Bryden et al., 2016). However, the effectiveness of many of those interventions remains largely unclear (Dyreborg et al, 2015). The Dutch National Institute for Public Health and the Environment (RIVM) has started a project with the ultimate goal of developing a database filled with effective safety interventions. Developers can submit their interventions using a fixed protocol. To support this project, we developed a survey, which was sent to all members of the Dutch Society for Safety Science (NVVK). In the survey, we used a list of 48 predefined descriptions of common interventions. Respondents could indicate whether they made use of these common interventions and the extent to which they considered these effective. The survey thus provided an extensive overview of the use and perceived effectiveness of 48 specific safety interventions. In the future, these insights can support the development and testing of more effective safety interventions.

In this article, the authors apply the intervention mapping (IM) protocol to develop safety leadership training for a rail infrastructure maintenance company. The IM protocol helps to create an evidence-based intervention in a structured way, based on concrete evidence. The application of IM within the occupational safety domain is limited, a research gap that this article bridges with the development and testing of a safety leadership intervention to promote safety behavior among managers. The company was positively and actively engaged in the training program thanks to the IM protocol. The local support group took full advantage of the opportunities to provide input during the development of the training’s various components. Despite this, interpersonal problems within the leadership team itself, such as a lack of psychological safety, were not identified during the needs assessment. These issues had an impact on the overall effectiveness of the training, as they manifested during the training when managers met physically for the first time in several years (due to the coronavirus). Our IM protocol will be adjusted accordingly for future applications, and we hope that sharing our experiences will enable fellow researchers to avoid this problem.

When a train passes a red aspect, this is called a Signal Passed at Danger event or SPAD. Sometimes it is easy to identify the SPAD cause but in other cases it is unclear why the incident occurred, especially if the system operated as usual and the train driver was trained and experienced just like his or her colleagues. In previous research, train driver deceleration behaviour has been shown to be influenced by frequent exposure in the previous 14 days to less restrictive and visually similar signal aspects in the same location. Previous exposure can contribute to SPAD causation unless the initial insufficient deceleration is corrected in time. Six years of SPAD data and red aspect approaches in the Netherlands was used to test whether previous exposure to yellow:number aspects corresponds with a statistically significant increase in SPAD incidents if there is a small window for correction available to drivers. The permitted track speed and signal distance influence the size of this window. The results provide evidence for previous exposure as a cause for SPADs and details to identify locations with increased SPAD probability. Changes in infrastructure and timetable design or adding safety measures for these locations can prevent future SPADs.

Background The recurrence of sentinel events (SEs) is a persistent problem worldwide, despite repeated analyses and recommendations formulated to prevent recurrence. Research suggests this is partly attributable to the quality of the recommendations, and determining if a recommendation will be effective is not yet covered by an adequate guideline. Our objectives were to (1) develop and validate criteria for high-quality recommendations, and (2) evaluate recommendations using the criteria developed. Methods (1) Criteria were developed by experts using the bowtie method. Medical doctors then determined if the recommendations of Dutch in-hospital SE analysis reports met the criteria, after which interobserver variability was tested. (2) Researchers determined which recommendations of Dutch perioperative SE analysis reports produced from 2017 to 2018 met the criteria. Results The criteria were: (1) a recommendation needs to be well defined and clear, (2) it needs to specifically describe the intended changes, and (3) it needs to describe how it will reduce the risk or limit the consequences of a similar SE. Validation of criteria showed substantial interobserver agreement. The SE analysis reports (n=115) contained 442 recommendations, of which 64% failed to meet all criteria, and 28% of reports did not contain a single recommendation that met the criteria. Conclusion We developed and validated criteria for high-quality recommendations. The majority of recommendations did not meet our criteria. It was disconcerting to find that over a quarter of the investigations did not produce a single recommendation that met the criteria, not even in SEs with a fatal outcome. Healthcare providers have an obligation to prevent SEs, and certainly their recurrence. We anticipate that using these criteria to determine the potential of recommendations will aid in this endeavour.

Employee behavior plays an important role in the occurrence and prevention of incidents, affecting safety margins. In this study, we examine the potential impact of incidental learning on human behavior in the presence of variation in task design. Incidental learning is the day-to-day on-the-job learning that occurs unintentionally. This learning influences which behavior (schema) is more likely to be activated in the employee’s brain. We posit that an incorrect schema can be activated and lead to undesired behavior if the employee is often exposed to (visually) similar tasks that require different behavior. In rail transport, there is a risk of trains passing through red signals. The train driver’s behavior plays an important role in preventing these signal passed at danger (SPAD) incidents. In this study we used speed and location data to analyze train driver deceleration behavior during red signal approaches in the Netherlands. The Dutch rail system showed variation in yellow signal aspects and signal distance. An analysis using 19 months of empirical data indicated changes in behavior when the employee had been previously exposed to different behavior requirements in the same location with a similar yellow signal. These results imply that task design can be improved by taking into consideration what an employee is exposed to during other moments of the shift, and not just during the execution of the specific task.

Research question: What is the influence of general management trends and research into causes of accidents on safety management? Method: The literature study is limited to English and Dutch books, documents and articles in the scientific, professional, and technical literature from the period 1988–2010. Results and conclusions: Quite some developments occurred in the occupational safety domain. During the period concerned three models are developed, the Dutch Tripod Model, the Swedish Occupational Risk Unit Model (QARU), and the Dutch Occupational Risk Model (QRM), a barrier based model founded on the bowtie metaphor. These models address occupational accidents from different perspectives, and surprisingly similar factors. While terminology differs, these factors are called basic risk factors, situational, or management factors. Self-regulation of companies has been a strong stimulus for research on safety management systems and audits. Traditionally research in management related topics has not been part of safety research, and thus it has to be developed. While the quality of this type of research is rather low, a general structure of safety management systems is related to the Rhineland management concept. Such evidence is found in new management models such as the EFQM/INK and, to a lesser extent, Corporate Social Responsibility (CSR). While organisational learning, its quality and effectiveness on occupational safety is not researched in this period, research interests are focussing on other organisational aspects like safety culture and climate, including a renewed interest in human behaviour.

Last minute risk assessment (LMRA) is a well-known work method to support employees’ risk perception. However, little is known about the effectiveness of LMRA in providing this support. Here, we describe an eye-tracking experiment with which we attempted to gain more insight into the relationship between LMRA and risk perception and to assess the difference between generic and specific supporting questions. Employees from an international energy production and desalination company participated in this experiment by assessing photographs portraying a (staged) work situation and deciding whether it was safe enough to continue activities and which risk factors were present or absent. The results show a consistent interaction effect over several parameters between work experience and the type of supporting questions, indicating that generic and specific supporting questions should be considered complimentary to each other. Furthermore, the results revealed several other challenges concerning real-world application of the LMRA.

Objective: What is the influence of general management trends and safety research on managing safety? Method: A literature study which is limited to original English and Dutch books, documents, and articles in relevant scientific journals, for the period 1988–2010. Results and conclusions: Safety science does not yet have a unifying theory, which betrays its young age as a scientific discipline. In the period concerned, well-known theories, models and metaphors are established or re-issued, including the High Reliability Theory, the Man-Made Disasters and the corresponding Disaster Incubation Theory, and the Normal Accident Theory. The Swiss cheese metaphor takes its final form, the bowtie metaphor and the Drift into Danger model are published. All these theories, models and metaphors emphasize organisational aspects of major accidents in high-tech-high-hazard sectors. General management trends highlight the importance of external stakeholders, which are only reflected in the Drift into Danger metaphor. These developments must be considered in the context of a dynamic influence of external factors, like a decrease in government influence coinciding with strong market and technology developments, which can conflict with safety requirements for high-tech-high-hazard companies. Organisational/safety culture and risk/safety management systems take off during this period, both in terms of academic research and consultancy activities for companies. Whether these concepts will have a lasting influence on safety levels in companies is yet to be seen, given the unclear relationship with major accident processes. Research findings show that many companies suffer from sloppy management, having only a limited insight into possible disaster scenarios.

Ever since safety started to be investigated in a consistent manner, around 150 years ago, there has been a tremendous improvement, both in our understanding of accident processes, and in reduction of harm and damage caused by these occupational and major accidents. Major improvements in safety theories, models and metaphors were made after World War II, with the late 1970s till the late 1990s as the ‘golden years’. But still these major accidents occur and they will keep prompting future scientific developments in safety, as they have done in the past. Reducing the frequency of major accidents remains challenging. Improving design and automation, as starting point for safety has its limits due to the complexity of processes and the inability to foresee all safety related conflicts. The modern emphasis to assure the capacity to handle unforeseen events, such as resilience promises to deliver, will become even more important in the future. Inherent safe design on the other hand make a sensible approach when designing production processes for emerging and future technologies, like nano- and biotechnology. Also, it will remain difficult for small and medium sized enterprises to adhere to complicated laws and regulations. In addition, an increased participation of stakeholder groups makes future safety decision-making even more challenging than it already is today. Yet we foresee that there may be grounds for change in which safety rules, laws and regulations are set aside, the bureaucratic approach towards safety is stopped and the focus is on dynamic accident processes detection. Today, methods are developed to automatically assess time-dependant advancement of accident scenarios and barrier degradation. This direction will contribute substantially to a future higher level of safety in different industrial sectors and might alleviate the emphasis on bureaucracy. We end with developments in two countries where safety and safety science is emerging.

The field of safety and incident prevention is becoming more and more data based. Data can help support decision making for a more productive and safer work environment, but only if the data can be, is and should be trusted. Especially with the advance of more data collection of varying quality, checking and judging the data is an increasingly complex task. Within such tasks, cognitive biases are likely to occur, causing analysists to overestimate the quality of the data and safety experts to base their decisions on data of insufficient quality. Cognitive biases describe generic error tendencies of persons, that arise because people tend to automatically rely on their fast information processing and decision making, rather than their slow, more effortful system. This article describes five biases that were identified in the verification of a safety indicator related to train driving. Suggestions are also given on how to formalize the verification process. If decision makers want correct conclusions, safety experts need good quality data. To make sure insufficient quality data is not used for decision making, a solid verification process needs to be put in place that matches the strengths and limits of human cognition.

In The Netherlands, approximately 2.300 workers have a serious reportable accident at work every year, of which around 60 are fatal (Bellamy et al., 2014). Safety professionals employ many methods to improve safety for workers within their companies. Interventions might, for example, be aimed at improving companies’ overall ‘safety culture’, at the introduction of a safety management system (e.g. Robson et al., 2007), or at improving the compliance of workers to specific safety rules (e.g. Peuscher and Groeneweg 2012; Bryden et al., 2016). The effectiveness of many of those interventions remains however largely unclear (Dyreborg et al, 2015). The Dutch National Institute for Public Health and the Environment (RIVM) has started a project with the ultimate goal of developing a database filled with ‘effective safety interventions’. The interventions can be submitted by their developers using a fixed protocol. To support this project, a survey was developed, which was sent to all members of the Dutch Society for Safety Science (NVVK). In the survey, a list of 48 predefined descriptions of common interventions was used. Respondents indicated whether they made use of these common interventions and the extent to which they considered these effective. The survey thus provided an extensive overview of the use and perceived effectiveness of 48 specific safety interventions. In the near future, these insights can support the development and testing of more effective safety interventions.

The origin of occupational safety, as an area of main interest of the government, the industry, the unions, and scientists starts in the Netherlands at the end of the 19th century. Roughly in the same period occupational medicine becomes a separate domain. Only just after World War II are safety professionals organised in associations. Starting as a ‘Club/werkgroep van veiligheidsinspecteurs’ (Club/Working group of Company Safety Inspectors) in 1947, it changes in 1962 into the ‘Nederlandse Vereniging van Veiligheidstechnici, NVVT’ (Dutch Association of Safety Technicians). In 1978 there is another change into a professional association, and the ‘Nederlandse Vereniging van Veiligheidskundigen, NVVK’ (Dutch Association of Safety Professionals) is formed. In 1986 this association is transformed into a knowledge association, the ‘Nederlandse Vereniging voor Veiligheidskunde, NVVK’ (Dutch Association of Safety Science). Nowadays the NVVK is still a knowledge platform for and by safety experts in the Netherlands. The association is a network of 3000 safety experts in various disciplines and departments, and by far the biggest network of experts on working conditions in the Netherlands. The NVVK is actively involved in changes in legislation and regulations, and also represents the interests of members and safety experts in general. During these 71 years of organised safety professions, major changes in position and content have occurred.

Objective: Which general management and safety models and theories trends influenced safety management in the period between Three Mile Island in 1979 and Piper Alpha in 1988? In which context did these developments took place and how did this influence Dutch safety domain? Method: The literature study was limited to original English and Dutch documents and articles in scientific and professional literature during the period studied. Results and conclusions: Models and theories of human errors, explaining occupational accidents were still popular in the professional literature. A system approach was introduced into mainstream safety science, starting in process safety, and subsequently moving into occupational safety. Accidents were thought to be the result of disturbances in a dynamic system, a socio-technical system, rather than just human error. Human errors were also perceived differently: they were no longer faults of people, but consequences of suboptimal interactions during process disturbances. In this period quality of safety research increased substantially, also in the Netherlands. Major disasters in the 1980s generated knowledge on process safety, and soon process safety outplaced developments in occupational safety, which had been leading before. Theories and models in this period had advanced sufficiently to explain disasters, but were still unable to predict probabilities and scenarios of future disasters. In the 1980s ‘latent errors’ appeared in safety literature, and in The Netherlands the concept of ‘impossible accidents’ appeared. Safety management was strongly influenced by developments in quality management.

Background
Organisations spend a considerable amount of time and effort on diagnosing and analysing risks within their organisation. In the area of occupational and process safety, a myriad of employee survey instruments is available. Many studies show that operational processes play an important role in an organisations overall safety. Yet, so far safety surveys mainly focus on safety measures or operational safety processes. A flexible instrument was developed with which a wide variety of constructs, from different disciplines, can be measured in a consistent and practical way. The resulting survey distinguishes itself from existing safety surveys by extending the scope with the operational processes which are also referred to as the ‘Core Business’.
Study
This study reports on the development of a catalogue of constructs which were derived from scientific literature and practice. Each of these constructs has been developed with a view towards measurability in an employee survey. The reliability and validity for fifteen of these constructs was assessed. Five separate projects have been conducted within a range of organisations operating as high risk industries.
Results
Construct validity and the dimensional structure of the instrument have been established through exploratory factor analysis and confirmed through confirmatory factor analysis. Diverse aspects derived from motivational and ergonomic approaches to safety proved to be distinguishable in this analysis.
Conclusion
The described instrument allows the mapping and quantification of various aspects of the operational process that are, based on existing knowledge, related to the occurrence of incidents.