Safety II

Introduction

• Over the last 70 years, the field of safety has progressed through various frameworks.
  • Each subsequent safety framework has built upon the previous framework to better display an understanding of processes and event analysis.
  • The goals of each framework are different, initiating a different process for analyzing safety events.
• Additionally, regulatory requirements often drive the safety process in place.
  • In the 1950s, the number of anesthesia mortalities increased, and safety frameworks were developed to mitigate the potential for safety problems.
  • Continued increases in medical malpractice and safety events have encouraged organizations to improve how they analyze these events.^1,2 For example, a sentinel event would initiate a root cause analysis (RCA) in many organizations based on its response to Joint Commission Organization standards.

Safety Frameworks

• Safety-0 is the oldest framework that relies on individual failure, staffing, education, and other basic standards to describe the cause of an event.
• Safety-1 is the framework that most healthcare organizations use. It is focused on systems-related problems, safety analytics, and organizational culture.^3-5
• Safety-2 is a newer concept described by many teams in aviation and other nuclear power industries. It highlights the importance of human performance and the worker’s ability to adapt to an ever-changing world to mitigate errors and improve system performance.^3-5

Comparing Safety-1 and Safety-2

• The focus of Safety-1 is on the small percentage of errors. The focus of Safety-2 is on the small percentage of errors and the overwhelmingly large percentage of good outcomes while trying to better understand the good outcomes (Figure 1).
• The concepts in Safety-2 focus on the power and importance of human performance and a team member’s ability to be adaptable. It also emphasizes learning from others “how to do it well.”
  • Safety-2 is not focused on placing blame on individual failure, poor staffing, or lack of education, which is often part of Safety-1.
  • For example, if the same procedure is done 100 times, why does it go well 98/100 times? What were the consistent elements of the 98 procedures? (Figure 1, Table 1)

• Safety-2 emphasizes the workers as the “asset” rather than the “liability.”
  • Understanding the true workflow and processes for the team is of utmost importance to the Safety-2 framework.
  • Safety-2 seeks to understand how day-to-day work is completed, not how it is imagined to be completed.
  • For example, if a barcode scanner is supposed to scan medications before “safe” administration, but it rarely works, the natural tendency will be to stop utilizing the technology that is lacking.

Concepts of Safety-2

• The underlying theme of Safety-2 concepts is that understanding both a system and its workers is paramount in recognizing its failures and successes.
  • Sidney Dekker’s concept of “drift into failure” examines stepwise deviations from a normal practice that eventually lead to the failure of a system.⁶
  • “Work-as-imagined versus work-as-done” highlights the reality of how everyday work is completed.
  • “Efficiency thoroughness trade-off” focuses on the push and pull of efficiency and thoroughness and how each of these changes in varying system.⁷
  • Resilience engineering highlights that teams and systems have to function in a way that they can anticipate – monitor – respond – and learn from ongoing problems and processes while utilizing these opportunities to make adaptations to apply to organizational processes. (Figure 2)
  • Todd Conklin has identified the 5 Principles of Human Performance (Figure 3), which are instrumental in better understanding the “why” of workers’ performance and the principles that guide performance within organizations.

• While these concepts are theoretical, they do highlight the importance of gaining a true understanding of processes to analyze the potential for failure.
• Additionally, comparing processes to those of other departments, individuals, or organizations who are doing something “well” helps to improve their own systems as they evolve and adapt.
• Discussing normal safety standards and understanding how the team members would function in the system is important to understand how processes move forward within systems.