Safety II: A Novel Approach to Reducing Harm

Abstract

Traditional safety efforts in healthcare have relied on learning from mistakes. This method (termed “Safety I”) includes error identification and reporting, investigation, and subsequent policy and procedure revisions if needed. Believing the Safety I approach can eliminate harm derives from evidence that standardizing work improves reliability and quality, which both affect safety. However, the Safety I approach has limitations due to the complexity of patients and healthcare delivery, making pre-planned, stable solutions to every possible situation impossible. Furthermore, as harm events become increasingly rare, there is less opportunity to learn from each occurrence, with events becoming “one-offs” unrelated to prior harm. Thus, if an organization’s goal is zero harm, the Safety I approach alone may be insufficient to reach that ambitious target. The solution may lie in a new approach – “Safety II.” The key philosophy of Safety II is that individuals and systems usually perform well, even under varying conditions. By understanding why things usually go right, even when they might not, and increasing the capability to handle unanticipated or unusual scenarios, patient safety will improve. Safety II leaders (psychologists, philosophers, systems and resilience engineers, and healthcare professionals) have proposed four highly interrelated activities believed to increase odds that systems will succeed during unpredictable conditions and improve outcomes: Monitor, Anticipate, Respond, and Learn. By using an illustrative case example, we will outline how Safety II practices can avoid harm in the healthcare setting.

Chapter Review Questions

• 1. Which of the following are key differences between Safety I and Safety II?

  • A. Safety I focuses on what went wrong. Safety II focuses on what went right.

  • B. Both Safety I and Safety II see humans as a liability, to be “designed” out of systems.

  • C. Safety I tends to focus on making systems more rigid, while Safety II focuses on making systems more flexible.

  • D. All of the above.

  • E. A and C.

  Answer: E is correct – Safety II sees human foresight and ingenuity as an asset toward improving safety. The key features of Safety II are that by allowing flexibility/adaptation/resilience to complex or unexpected circumstances, we can proactively prevent errors from ever occurring.

• 2. What are the four main potentials/components of Safety II?

  • A. Monitor, Anticipate, Respond, Learn

  • B. Monitor, Avert, React, Leave

  • C. Investigate, Restrict, Enforce, Discipline

  • D. Monitor, Reason, Action, Lesson

  Answer: A. Hollnagel proposes that Safety II involves four integrated actions as listed in (A). We suggest that two of these – Monitor and Anticipate – might be seen as “Recognize.”

• 3. Which of the following statements is false regarding the shortcomings of Safety I?

  • A. Learning does not occur until after a critical event has occurred.

  • B. Over time, errors become unusual and unique making learning from events challenging.

  • C. The result is often increased rules and regulations.

  • D. Human error is not considered in the analysis of events.

  Answer: D. The first three answers are all problems with the Safety I approach. This does not mean that Safety I is useless, but that addition of Safety II to our toolkit will improve safety further. Safety I often assesses for human errors leading to harm.

• 4. What are the three main components of resilience?

  • A. Toughness, Plasticity, Recoil

  • B. Foresight, Coping, Recovery

  • C. Anticipation, Flexibility, Recoil

  • D. Mindfulness, Anticipation, Recovery

  Answer: B. “Resilience” is the ability of an individual or system to function under circumstances beyond the usual or outside conditions for which the system was designed. Therefore, coping and then recovering to normal function are required.

• 5. Which of the following statements is true regarding the weaknesses of a FMEA (failure modes and effects analysis)?

  • A. Has limited value in error prevention as the scope is often too broad

  • B. Primarily focuses on preventing predictable problems

  • C. Is a core tool in Safety II methodology

  • D. Often addresses all potential errors preemptively

  Answer: B. While FMEA is useful, the process is still limited because of the requirement to imagine well in advance things that might go wrong and then make strategic decisions about which possible failure modes to design out of a system. Safety II allows for coping with previously unimaginable circumstances effectively.

• 6. Which of the following safety approaches praises individuals who perform well with the attempt to learn how to respond to the same conditions in the future?

  • A. Learning from experience

  • B. Learning from praise

  • C. Learning from positivity

  • D. Learning from excellence

  Answer: D. Learning from Excellence describes reporting and analysis of actions individuals took to succeed in a situation. Then the analysis is used to improve safety in similar situations in the future.

• 7. Which of the following is true regarding the difference between Safety I and Safety II methodologies?

  • A. The intention is for Safety II to replace Safety I as it is more effective at preventing safety events in the healthcare setting.

  • B. Safety I efforts are focused on the primary prevention of events, while Safety II evaluates events after they have occurred.

  • C. Safety I considers deviation in actions to be a liability, while Safety II considers intentional variation by humans as positive and necessary.

  • D. Safety I involves deviation from the protocol, while Safety II stresses the importance of following institution policies and procedures.

  Answer: C. Safety II does not replace Safety I. However, Safety II recognizes that flexibility in actions can help a system to “bend and not break.”

• 8. Predictive analytics, which leverages previously acquired data to develop predictions about the future, is an example of which of the four main Safety II components?

  • A. Anticipate

  • B. Learn

  • C. Resilience

  • D. Respond

  Answer: A. The anticipating step of Safety II requires the ability to predict the future. While humans may do this based on experience, heuristics, or “gut instinct,” technological advances in predictive analytics may augment our ability to know when an event is about to occur.