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”

Document Type : Commentary


1 School of Psychology, University of Leeds, Leeds, UK

2 Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK


Mannion and Braithwaite outline a new paradigm for studying and improving patient safety – Safety II. In this response, I argue that Safety I should not be dismissed simply because the safety management strategies that are developed and enacted in the name of Safety I are not always true to the original philosophy of ‘systems thinking.’


Main Subjects

  1. Lawton R. Not working to rule: Understanding procedural violations at work. Saf Sci. 1998;28(2):77-95. doi:10.1016/S0925-7535(97)00073-8
  2. 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
  3. Braithwaite J, Wears RL, Hollnagel E. Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done. CRC Press; 2016.
  4. Anderson JE, Ross AJ, Back J, et al. Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol. Pilot Feasibility Stud. 2016;2(1):61. doi:10.1186/s40814-016-0103-x
  5. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.
  6. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43.
  7. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007;334(7584):79. doi:10.1136/bmj.39031.507153.AE
  8. 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
  9. Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf. 2012;21(5):369-380. doi:10.1136/bmjqs-2011-000443
  10. Vincent C, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Qual Saf. 2014;23(8):670-677. doi:10.1136/bmjqs-2013-002757
  11. Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. doi:10.1136/qhc.13.suppl_2.ii28
  12. Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232
  13. Donaldson LJ, Appleby L, Boyce J. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. Norwich, United Kingdom: Stationery Office; 2000.
  14. Cullen WD. The Ladbroke Grove rail enquiry: part 1 report. London: HMSO; 2001.
  15. Sujan M, Huang H, Braithwaite J. Why do healthcare organisations struggle to learn from experience? A safety-II perspective. Proceedings of Healthcare Systems Ergonomics and Patient Safety Conference (HEPS). Toulouse, France; 2016.
  16. Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. Ann Fam Med. 2017;15(5):455-461. doi:10.1370/afm.2123
  17. Cohen D. Back to blame: the Bawa-Garba case and the patient safety agenda. BMJ. 2017;359:j5534. doi:10.1136/bmj.j5534
  18. Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. BMJ Qual Saf. 2017;26(8):622-631. doi:10.1136/bmjqs-2016-005570
  19. Taylor N, Lawton R, Slater B, Foy R. The demonstration of a theory-based approach to the design of localized patient safety interventions. Implement Sci. 2013;8:123. doi:10.1186/1748-5908-8-123
  • Receive Date: 03 December 2017
  • Revise Date: 18 February 2018
  • Accept Date: 06 February 2018
  • First Publish Date: 01 July 2018