Rethinking learning from incidents in healthcare: a Safety-II model integrating work-as-imagined, work-as-done, and work-as-experienced

Summary

Healthcare organisations increasingly investigate patient safety incidents using systems thinking. However, even investigations that claim to adopt a systems approach frequently revert to linear, event-focused reasoning - looking for on specific issues that went wrong in one particular incident, and assuming that fixing those issues will stop it happening again.

A foundational question remains unresolved: when an incident review identifies a “deviation,” does this represent exceptional behaviour or the system's typical mode of operation that generally succeeds under varying conditions but occasionally fails? Without this distinction, explanations for incidents tend to focus on individual non-compliance rather than understanding the everyday adaptations that enable care delivery in a complex adaptive system. Consequently, incident reviews that promote system learning often continue to recommend retraining, reminders, and reinforced compliance.

In this article, the authors propose a different approach based on Safety-II, which focuses on understanding how care is successfully delivered most of the time. They suggest looking at incidents through three perspectives:

• Work as imagined – how people think work should happen according to policies and procedures.
• Work as done – how work actually happens in day-to-day practice.
• Work as experienced – how patients and families experience care over time, including things that healthcare staff may not see because care is spread across different services and organisations.