A Safety-II Perspective on Organisational Learning in Healthcare Organisations; Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

Document Type : Commentary

Author

Warwick Medical School, University of Warwick, Coventry, UK

Abstract

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.

Keywords

Main Subjects


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
Hollnagel E. Is safety a subject for science? Saf Sci. 2014;67:21-24. doi:10.1016/j.ssci.2013.07.025
Hollnagel E, Woods DD, Leveson N. Resilience Engineering: Concepts and Precepts. Aldershot, UK: Ashgate; 2006.
Martinie C, Palanque P, Ragosta M, Sujan MA, Navarre D, Pasquini A. Understanding Functional Resonance through a Federation of Models: Preliminary Findings of an Avionics Case Study. In: Bitsch F, Guiochet J, Kaâniche M. Computer Safety, Reliability, and Security: 32nd International Conference, SAFECOMP 2013, Toulouse, France, September 24-27, 2013. Proceedings. Berlin, Heidelberg: Springer Berlin Heidelberg; 2013:216-227.
Braithwaite J, Wears RL, Hollnagel E. Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done. Farnham: Ashgate; 2016.
Hollnagel E, Braithwaite J, Wears RL. Reslient Health Care. Farnham: Ashgate; 2013.
Wears R, Hollnagel E, Braithwaite J. The Resilience of Everyday Clinical Work. Farnham: Ashgate; 2015.
Back J, Ross AJ, Duncan MD, Jaye P, Henderson K, Anderson JE. Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience. Ann Emerg Med. 2017;70(5):659-671. doi:10.1016/j.annemergmed.2017.04.032
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
Department of Health. An organisation with a memory. London: The Stationery Office; 2000.
National Advisory Group on the Safety of Patients in England. A promise to learn - a commitment to act. London: Department of Health; 2013.
Macrae C. The problem with incident reporting. BMJ Qual Saf. 2015. doi:10.1136/bmjqs-2015-004732
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2016. doi:10.1136/bmjqs-2016-005511
Sujan MA, Ingram C, McConkey T, Cross S, Cooke MW. Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions. BMJ Qual Saf. 2011;20(6):549-556. doi:10.1136/bmjqs.2010.048348
Pasquini A, Pozzi S, Save L, Sujan MA. Requisites for successful incident reporting in resilient organisations. In: Hollnagel E, Paries J, Woods DD, Wreathall J. Resilience engineering in practice : a guidebook. Farnham: Ashgate; 2011:237-254.
Sujan MA, Pozzi S, Valbonesi C. Reporting and Learning: From Extraordinary to Ordinary. In: Braithwaite J, Wears R, Hollnagel E. Resilient Health Care III: Reconciling Work-as-Imagined with Work-as-Done. Farnham: Ashgate; 2016.
Easterby-Smith M, Crossan M, Nicolini D. Organizational Learning: Debates Past, Present And Future. Journal of Management Studies. 2000;37(6):783-796. doi:10.1111/1467-6486.00203
Carroll JS, Edmondson AC. Leading organisational learning in health care. Qual Saf Health Care. 2002;11(1):51-56. doi:10.1136/qhc.11.1.51
Popper M, Lipshitz R. Organizational learning mechanisms: A structural and cultural approach to organizational learning. J Appl Behav Sci. 1998;34(2):161-179. doi:10.1177/0021886398342003
Baines RJ, Langelaan M, de Bruijne MC, et al. Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. BMJ Qual Saf. 2013;22(4):290-298. doi:10.1136/bmjqs-2012-001126
Landrigan  CP, Parry  GJ, Bones  CB, Hackbarth  AD, Goldmann  DA, Sharek  PJ. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med. 2010;363(22):2124-2134. doi:10.1056/NEJMsa1004404
Vincent C, Aylin P, Franklin BD, et al. Is health care getting safer? BMJ. 2008;337. doi:10.1136/bmj.a2426
Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18(1):11-21. doi:10.1136/qshc.2007.024166
Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care. 2006;15(6):393-399. doi:10.1136/qshc.2005.017525
Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017;26(5):381-387. doi:10.1136/bmjqs-2016-005991
Westbrook JI, Li L, Lehnbom EC, et al. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care. 2015;27(1):1-9. doi:10.1093/intqhc/mzu098
Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Soc Sci Med. 2011;73(2):217-225. doi:10.1016/j.socscimed.2011.05.010
Cook R. Resilience, the Second Story, and progress on patient safety. In: Hollnagel E, Braithwaite J, Wears R. Resilient Health Care. Farnham: Ashgate; 2013:19-26.
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety: recommendations of the project ‘safety improvement for patients in Europe’. Int J Qual Health Care. 2009;21(3):169-175. doi:10.1093/intqhc/mzp015
Raben DC, Bogh SB, Viskum B, Mikkelsen KL, Hollnagel E. Learn from what goes right: A demonstration of a new systematic method for identification of leading indicators in healthcare. Reliability Engineering & System Safety. 2018;169:187-198. doi:10.1016/j.ress.2017.08.019
Braithwaite J, Clay-Williams R, Hunte GS, Wears RL. Understanding resilient clinical practices in Emergency Department ecosystems. In: Braithwaite J, Wears RL, Hollnagel E. Resilient Health Care III: Reconciling Work-As-Imagined and Work-As-Done. Farnham: Ashgate; 2016:115-132.
Debono D, Braithwaite J. Workarounds in nursing practice in acute care: A case of a health care arms race? In: Wears R, Hollnagel E, Braithwaite J. The Resilience of Everyday Clinical Work. Farnham: Ashgate; 2015.
Perry SJ, Wears RL. Underground adaptations: case studies from health care. Cognition, Technology & Work. 2012;14(3):253-260. doi:10.1007/s10111-011-0207-2
Sujan M, Spurgeon P, Cooke M. Translating tensions into safe practices through dynamic trade-offs: The secret second handover. In: Wears R, Hollnagel E, Braithwaite J. The Resilience of Everday Clinical Work. Farnham: Asghate; 2015:11-22.
Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emergency care. Reliability Engineering & System Safety. 2015;141:54-62. doi:10.1016/j.ress.2015.03.006
Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2015;20(1_suppl):17-25. doi:10.1177/1355819614560449
Sujan MA, Huang H, Braithwaite J. Learning from incidents in health care: Critique from a Safety-II perspective. Saf Sci. 2017;99:115-121. doi:10.1016/j.ssci.2016.08.005
Sujan M, Huang H, Braithwaite J. Why do healthcare organisations struggle to learn from experience? A Safety-II perspective. In: Mollo V, Falzon P. Healthcare Systems Ergonomics and Patient Safety (HEPS). Toulouse; 2016.
Sujan M. An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. Reliability Engineering & System Safety. 2015;144:45-52. doi:10.1016/j.ress.2015.07.011
Wenger EC, Snyder WM. Communities of practice: The organizational frontier. Harv Bus Rev. 2000;78(1):139-146.
Coopey J, Burgoyne J. Politics and Organizational Learning. Journal of Management Studies. 2000;37(6):869-886. doi:10.1111/1467-6486.00208
Edmondson AC, Higgins M, Singer S, Weiner J. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Res Hum Dev. 2016;13(1):65-83. doi:10.1080/15427609.2016.1141280
Chuang S, Wears R. Strategies to get resilience into everday clinical work. In: Wears R, Hollnagel E, Braithwaite J. The Resilience of Everday Clincal Work. Farnham: Ashgate; 2015:225-234.
Clay-Williams R, Hounsgaard J, Hollnagel E. Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implement Sci. 2015;10(1):125. doi:10.1186/s13012-015-0317-y
Grote G. Promoting safety by increasing uncertainty – Implications for risk management. Saf Sci. 2015;71:71-79. doi:10.1016/j.ssci.2014.02.010
Wears R, Hunte G. Resilient procedures - Oxymoron or innovations? In: Braithwaite J, Wears R, Hollnagel E. Resilient Health Care III: Reconciling Work-as-Imagined with Work-as-Done. Farnham: Ashgate; 2016.
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliability Engineering & System Safety. 2012;101:21-34. doi:10.1016/j.ress.2011.12.021
Canfield C. Recovery to Resilience: A Patient Perspective. In: Braithwaite J, Wears R, Hollnagel E. Resilient Health Care III: Reconciling Work-as-Imagined and Work-as-Done. Boca Raton: CRC Press; 2016:27-36.
Chuang S, Hollnagel E. Challenges to implementing resilient health care. In: Braithwaite J, Wears R, Hollnagel E. Resilient Health Care III: Reconciling Work-as-Imagined and Work-as-Done. Boca Raton: CRC Press; 2016:47-55.
Johnson A, Lane P. Resilience Work-As-Done in everyday clinical work. In: Braithwaite J, Wears R, Hollnagel E. Resilient Health Care III: Reconciling work-as-imagined with work-as-done. Farnham: Ashgate; 2016:96-114.