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Safety-I and Safety-II

It is necessary to put the focus on how health care systems succeed and stop perpetuating the myopic focus on how they fail.
Erik Hollnagel 2016

In the late 1990s a study was undertaken in England to estimate the level of harm to patients from adverse events. This led to the statistic we use today in the NHS of around 10% of patients will be harmed by the care provided. This study was included in the seminal report in relation to patient safety in England; An Organisation with a Memory published by the Department of Health in 2000. This triggered the approach we took in safety for the subsequent two decades. The methodology was to identify the failures via incident reporting systems, investigate the failures using root cause analysis and disseminate alerts and solutions to minimise or eliminate those failures. This approach has now been coined by some as ‘safety-I’. Safety-I is defined as ‘a state where as few things as possible go wrong’.

Safety-I mirrors society where in life we pay more attention to the negative things; negativity is considered more impactful than positivity. As a result, those that work in patient safety change healthcare systems, processes, and practices based on the negative things that happen. The failures, mistakes, errors, patient safety incidents, serious incidents, never events, complaints and claims. However, no organisation or team or individual can be understood or fixed by focusing on failure alone.

If we return to that statistic of 10%, one could ask, what about the 90%? What is happening when nothing bad is happening? If we look at the definition of safety, we find it is about when we are kept safe from harm; not when we are harmed. Harm is when safety has failed. So instead of purely focusing on the small percentage of things that go wrong we should be looking at the 90% of times that things go ok in order to understand how safe our systems, processes and practices are. Study the daily activities of clinical work that functions and unfolds as it should, as it is expected and planned. This has been coined as ‘safety-II. Safety-II is defined as ‘a state where as much as possible goes right’.

It is important to note that safety-II does not replace safety-I. Safety-II is safety-I and safety II thinking bought together. We still need to capture when things do go wrong and when we do, safety experts should seek to answer a vital question ‘why has it failed this time when most of the time it goes ok?’.

In order to apply safety-II in healthcare, it is necessary to understand what kind of system healthcare is. To understand how a system functions there is a need to study the properties and characteristics of the entire system; the dynamics, the independent and interdependent relationships that make up the system, and the emergent behaviours of the system. The current safety models and methods assume that systems are linear with resultant outcomes. In fact, healthcare is far from a linear system, and outcomes are emergent rather than resultant. Importantly, we need to be careful when attributing cause and effect in a complex adaptive system. As the system is dynamic, it does not necessarily respond to intended change as predicted. Healthcare delivery is transitory so even if there is an attempt to understand it at one time it will have changed before that understanding has been fully explained.

Healthcare is considered a complex adaptive system which is dynamic, unpredictable, constantly changing sometimes minute by minute. Too often we try to simplify healthcare into a complex problem and seek a simple solution. We try to implement solutions that are inappropriate for the degree of complexity. Interventions that are not designed for complex systems will not make a difference to the everyday reality. Safety-II forces us to consider the dynamic and non-dynamic properties of healthcare and the varying characteristics, forces, variables and influences across it. If we want to change or improve or strengthen a complex system like healthcare, we need to look for patterns in the behaviour of the system. We need to look for interconnections within the system rather than isolated problems.

Therefore, if we are to understand how safe healthcare is we should study how it works day in day out. Working out how it almost always goes right despite the obstacles and difficulties. How effective the adaptations and adjustments are that actually enable healthcare staff to work safely and seek to replicate and strengthen these.