It Ain’t What You Do (But the Way That You Do It): Will Safety II Transform the Way We Do Patient Safety; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice” (original) (raw)
Related papers
Systems Thinking and Patient Safety
2005
Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that "first, do no harm" has been the ethical watchword throughout the history of medicine, nursing, and pharmacy. In recent years, we have become increasingly aware of the magnitude of our failure to successfully live up to this ethical imperative. We have also become increasingly aware of techniques that we might employ to bring reality closer to the ideal of doing no (preventable) harm. The realization of the magnitude of this failure and that there are potential routes to reducing harm has fortunately resulted in both a burgeoning of research in the area of patient safety and a willingness to invest in patient safety research. This volume-published by the Agency for Healthcare Research and Quality (AHRQ) with support from the U.S. Department of Defense-along with its three companion volumes, is testimony to this blossoming of research and funding.
2018
In their editorial, Mannion and Braithwaite contend that the approach to solving the problem of unsafe care, Safety I, is flawed and requires a shift in thinking to what they are calling Safety II. We have reservations as to whether by itself the shift from Safety I to Safety II is sufficient. Perhaps our failure to improve outcomes in the field of patient safety and quality lies less in our approach – Safety I vs. Safety II – and more in the lack of an agreed upon, commonly understood set of core competencies (knowledge, skills, and attitudes) needed in its workforce. The authors explore in this commentary the need to establish core competencies as part of the pathway to professionalism for the discipline of patient safety and quality.
2018
Who could disagree with the seemingly common-sense reasoning that: " We must learn from the things that go wrong. " ? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some researchers to argue that there is more to be gained by learning from the majority of healthcare episodes: the things that go right. Based on this premise, so-called Safety-II has emerged as a new paradigm. In this commentary, we consider the ongoing value of Safety-I based approaches and explore whether now is the time to abandon learning from " the bad " and re-energise data collection and analysis by focusing on " the good. " Citation: Carson-Stevens A, Donaldson L, Sheikh A. The rise of patient Safety-II: should we give up hope on Safety-I and extracting value from patient safety incidents? Comment on " False dawns and new horizons in patient safety research and practice.
False Dawns and New Horizons in Patient Safety Research and Practice Editorial
2017
In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systems-level improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems. Citation: Mannion R, Braithwaite J. False dawns and new horizons in patient safety research and practice.
False Dawns and New Horizons in Patient Safety Research and Practice
International journal of health policy and management, 2017
In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systems-level improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems.
2018
In a recent edition of this journal, Mannion and Braithwaite provide a succinct analysis of the emergence, and ultimately limited impact, of what they term the current 'Safety I' movement in healthcare. They describe the arc of this field from denial, through engagement via mechanisms and approaches imported from other industries, to the current situation where, despite 'best efforts, ' error rates remain stubbornly recalcitrant. In examining the failure of system-wide efforts to produce sustained reductions in errors and adverse events, that article exposes the doxa, or what Bourdieu calls 'the taken for granted' which is central to this latest wave of patient safety movement. In this commentary, I would like to take focus on two key elements of Mannion and Braithwaite's argument: that harm is caused by misguided but otherwise well-intentioned actions and the 'embracing' of patient safety. I then conclude by briefly considering the implications of these for Safety II, particularly as envisaged by the authors as an evolutionary, and therefore linear progression, from Safety I. Citation: Travaglia J. Disturbing the doxa of patient safety: Comment on " False dawns and new horizons in patient safety research and practice.
2018
In their recent editorial Mannion and Braithwaite provide an insightful critique of traditional patient safety improvement efforts, and offer a powerful alternative vision based on Safety-II thinking that has the potential to radically transform the way we approach patient safety. In this commentary, I explore how the Safety-II perspective points to new directions for organisational learning in healthcare organisations. Current approaches to organisational learning adopted by healthcare organisations have had limited success in improving patient safety. I argue that these approaches learn about the wrong things, and in the wrong way. I conclude that organisational learning in healthcare organisations should provide deeper understanding of the adaptations healthcare workers make in their everyday clinical work, and that learning and improvement approaches should be more democratic by promoting participation and ownership among a broader range of stakeholders as well as patients. Citation: Sujan M. A Safety-II perspective on organisational learning in healthcare organisations: Comment on " False dawns and new horizons in patient safety research and practice.
A critical appraisal of what organisational approaches are pivotal to improve patient safety
Background: Patient safety remains a priority for healthcare organisations globally. There remains little consensus regarding the extent of this issue and the resultant impact on both individuals and communities. Aim: Our study aims to provide healthcare organisations and decision makers with increased information regarding predictive risk factors to enhance patient safety, and develop an organisational culture of safety. Methods: This paper reviews current literature regarding patient safety and presents predictive risk factors and recommendations for healthcare organisations globally to measure and monitor patient safety. Results: Three categories of organisational factors promoting safety culture were identified-Focusing on system/culture, management support and team work and event reporting. Conclusions: This review strove to identify and discuss the predictive risk factors for patient safety and support the importance of a positive organisational culture and strong leadership in monitoring and reducing patient care errors and improving patient care in healthcare setting.
Transforming concepts in patient safety: a progress report
BMJ quality & safety, 2018
In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for H...
Patient safety: lessons learned
Pediatric Radiology, 2006
The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.