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”

Document Type: Commentary

Authors

1 Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK

2 London School of Hygiene and Tropical Medicine, London, UK

3 Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK

Abstract

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, socalled 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.”

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Main Subjects


  1. World Health Organization. Patient safety: making health care safer. http://apps.who.int/iris/bitstream/10665/255507/1/WHO-HIS-SDS-2017.11-eng.pdf. Published 2017.
  2. Resolution WHA55.18. Quality of care: patient safety. In: Fifty-fifth World Health Assembly, Geneva, 13–18 May 2002. Report No.: WHO document WHA55/2002/REC/1. Volume 1. Resolutions and decisions. Geneva: World Health Organization; 2002.
  3. Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care. 2004;13(4):242-243. doi:10.1136/qhc.13.4.242
  4. Edmondson AC. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55.
  5. Sujan MA, Habli I, Kelly TP, Pozzi S, Johnson CW. Should healthcare providers do safety cases? Lessons from a cross-industry review of safety case practices. Saf Sci. 2016;84:181-189. doi:10.1016/j.ssci.2015.12.021
  6. National Academy of Engineering, Institute of Medicine. Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. National Academies Press; 2011:340.
  7. Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. Ashgate Publishing, Ltd; 2014:200.
  8. Hollnagel E, Braithwaite J, Wears RL. Resilient Health Care. Ashgate Publishing, Ltd; 2013:296.
  9. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: a white paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia. http://www.qpsolutions.vn/cgi-bin/Document/Safety%20II%20WhitePaper.pdf. Published 2015.
  10. Pedersen KZ. Standardisation or resilience? The paradox of stability and change in patient safety. Sociol Health Illn. 2016;38(7):1180-1193. doi:10.1111/1467-9566.12449
  11. Mannion R, Braithwaite J. False Dawns and New Horizons in Patient Safety Research and Practice. Int J Health Policy Manag. 2017;6(12):685-689. doi:10.15171/ijhpm.2017.115
  12. Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. John Wiley & Sons; 2012:352.
  13. Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;379(9823):1310-1319. doi:10.1016/s0140-6736(11)61817-5
  14. Elliott RA, Putman KD, Franklin M, et al. Cost effectiveness of a pharmacist-led information technology intervention for reducing rates of clinically important errors in medicines management in general practices (PINCER). Pharmacoeconomics. 2014;32(6):573-590. doi:10.1007/s40273-014-0148-8
  15. Carson-Stevens A, Hibbert P, Williams H, et al. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Southampton (UK): NIHR Journals Library; 2016.
  16. Carson-Stevens A, Edwards A, Panesar S, et al. Reducing the burden of iatrogenic harm in children. Lancet. 2015;385(9978):1593-1594. doi:10.1016/s0140-6736(14)61739-6
  17. Berwick D. A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England. London: Department of Health; 2013;6.
  18. Department of Health. An organisation with a memory. http://webarchive.nationalarchives.gov.uk/20130105144251/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4065086.pdf.  Published 2001.
  19. Jha A, Pronovost P. Toward a safer health care system: the critical need to improve measurement. JAMA. 2016;315(17):1831-1832. doi:10.1001/jama.2016.3448
  20. Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010-2012. PLoS Med. 2014;11(6):e1001667. doi:10.1371/journal.pmed.1001667
  21. Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of incident reports. Br J Gen Pract. 2015;65(641):e829-837. doi:10.3399/bjgp15X687877
  22. Cooper A, Edwards A, Williams H, et al. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age Ageing. 2017;46(5):833-839. doi:10.1093/ageing/afx044
  23. Rees P, Edwards A, Panesar S, et al. Safety incidents in the primary care office setting. Pediatrics. 2015;135(6):1027-1035. doi:10.1542/peds.2014-3259
  24. Rees P, Edwards A, Powell C, et al. Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database. Vaccine. 2015;33(32):3873-3880. doi:10.1016/j.vaccine.2015.06.068
  25. Rees P, Edwards A, Powell C, et al. Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis. PLoS Med. 2017;14(1):e1002217. doi:10.1371/journal.pmed.1002217
  26. Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child. 2016;101(9):788-791. doi:10.1136/archdischild-2015-310021
  27. Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016;25(2):71-75. doi:10.1136/bmjqs-2015-004732
  28. Hibbert P, Runciman W, Deakin A. A Recursive Model of Incident Analysis. Australian Patient Safety Foundation; 2007.
  29. Carson-Stevens A, Donaldson LJ. Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners; 2017.
  30. Carson-Stevens A, Cooper A. Patient Safety and Quality Improvement in Primary Care. RCGP Learning. Royal College of General Practitioners; 2017. Accessed April 1, 2017.  http://elearning.rcgp.org.uk/course/info.php?popup=0&id=242.
  31. The Primary Medical Services (Oral Anti-coagulation with Warfarin) (Directed Enhanced Service) (Wales) Directions 2017 No. 14. Nov 4,  2017. http://www.wales.nhs.uk/sites3/docmetadata.cfm?  
  32. World Health Organization. Preliminary version of minimal information model for patient safety. World Health Organization; 2014. http://www.who.int/patientsafety/implementation/IMPS_working-paper.pdf.
  33. World Health Organization. The conceptual framework for the international classification for patient safety. WHO;2009:1-149.