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Found 61 results
  1. Content Article
    To understand and improve the way that organisations work, we must think in systems. This means considering the interactions between the parts of the system (human, social, technical, information, political, economic and organisational) in light of system goals. There are concepts, theories and methods to help do this, but they are often not used in practice. We therefore continue to rely on outdated ways of thinking in our attempts to understand and influence how sociotechnical systems work. This White Paper distils some useful concepts as principles to encourage a ‘systems thinking’ approach to help make sense of – and improve – system performance. It is hoped that these will give new ways of thinking about systems, work and safety, and help to translate theory into practice
  2. Content Article
    This study examines the variability in how different anaesthesia providers approach patient care, to provide insight into the source and necessity of variations in practice, the implications of different individual preferences and the subsequent consequences on approaches to safety that emphasise standardisation. The authors argue that the differences in how anaesthesia providers approach their work call into question whether ‘standardisation’ is always the best approach to improve safety in anaesthesia. They state that this work reinforces the idea that it is the humans in the system, with their flexibility and expertise, who are the primary source of everyday safety.
  3. Content Article
    Serious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.
  4. Content Article
    Nontechnical skills (NTS) are the behaviours and thought processes used by surgeons to make decisions, maintain awareness of the operating environment, communicate with and lead team members with the view to producing reliably safe outcomes. This qualitative research explored how surgeons deploy NTS to facilitate safe and effective outcomes from surgical interventions. The authors conclude that successfully understanding and engaging NTS is potentially more proactively useful to surgeons than feedback from more invasive techniques used by some approaches to safe operator assurance.
  5. Content Article
    This paper aims to explore the insights provided by Safety-I and Safety-II approaches by examining the practical application of two frequently used methods: Systematic Human Error Reduction and Prediction Approach (SHERPA) and Functional Resonance Analysis Method (FRAM). Neither method should be uniquely labelled as a Safety-I or Safety-II approach, however, SHERPA is traditionally used within a Safety-I context, and FRAM is frequently used within a Safety-II context. By examining the application of these two methods to the management of post-surgical deterioration, the authors critically reflect on the analysis logic embedded in each method and their potential contribution to improving patient safety.
  6. Content Article
    Many healthcare improvement approaches originated in manufacturing, where end users are framed as consumers. But in healthcare, greater recognition of the complexity of relationships between patients, staff, and services (beyond a provider-consumer exchange) is generating new insights and approaches to healthcare improvement informed directly by patient and staff experience. Co-production sees patients as active contributors to their own health and explores how interactions with staff and services can best be supported. Co-design is a related but distinct creative process, where patients and staff work in partnership to improve services or develop interventions. Both approaches are promoted for their technocratic benefits (better experiences, more effective and safer services) and democratic rationales (enabling inclusivity and equity), but the evidence base remains limited. This Element explores the origins of co-production and co-design, the development of approaches in healthcare, and associated challenges; in reviewing the evidence, it highlights the implications for practice and research.
  7. Content Article
    In the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support.  Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
  8. Content Article
    Triage and clinical consultations increasingly occur remotely. In this study, published in BMJ Quality & Safety, Payne et al. aimed to learn why safety incidents occur in remote encounters and how to prevent them. They found that rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer. As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported.
  9. Content Article
    This document outlines NHS England's approach to learning from safety culture best practice. It covers: Safety culture context within the NHS patient safety strategy Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities Case studies
  10. Content Article
    Safety-II is moving beyond the conceptual, with practical applications emerging from the fog of models and theory. But critics still point to a lack of evidence and limited real-world proof that the promise is justified. This blog reports on a webinar by Mark Sujan and Simon Gill that looked at how to implement Safety-II thinking in real world settings. The blog outlines different elements of the webinar including: a case study of anticipatory practice being used to reduce serious harm from falls in an emergency department a discussion on how to move towards a non-hierarchical clinical leadership challenges to adopting Safety-II principles evaluation of Safety-II: how do you measure a non-event?
  11. Content Article
    This newsletter from Psychological Safety, provides an overview of the two different concepts of Safety I and Safety II. Follow the link at the bottom of the page to read the article in full. 
  12. Content Article
    Safe and Sound is a podcast produced by the Barts Health Education Academy which aims to have honest, informative and educational discussions about patient safety and how it can be improved. In this episode, Dr Charlotte Hopkins, an HIV consultant who works in patient safety and Dr Annie Hunningher, a consultant anaesthetist and patient safety specialist, discuss the pros and cons between two different approaches to patient safety, Safety 1 and Safety 2.
  13. Content Article
    Simulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. The authors of this article describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, they suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focuses on systematically understanding how good performance is produced in frequent simulation scenarios.
  14. Content Article
    The Resilient Health Care Society (RHCS) is a non-profit organisation registered in Sweden. The goal of the Society is to provide an international forum for coordination and exchange of principles, practices, and experiences, by bringing together researchers and professionals working with or interested in Resilient Health Care. Research and practice in Resilient Health Care aims to develop and promote practical solutions, based on a solid scientific foundation, to ensure that health care systems can perform as intended under expected and unexpected conditions alike. Links to some of their publications can be found below.
  15. Content Article
    An set of presentations and resources from the Erasmus School of Health Policy & Management.
  16. Content Article
    After attending a Safety II workshop, Paul Stretton discusses what the future holds for the Safety II/Resilience Engineering community.
  17. Content Article
    Patient safety is typically assessed by the frequency of adverse events or incidents, which means we seek to determine safety by its absence rather than its presence. The Safety-II perspective aspires to overcome this paradox by bringing into focus situations where safety is actually present, that is, in everyday work that usually goes well. Central to Safety-II is the notion that, in complex systems such as healthcare, safety is a consequence of collective efforts to adapt to dynamic conditions and uncertainty, rather than the natural state of a system where nothing untoward happens. This type of thinking has been met with significant interest and enthusiasm in healthcare, because it feeds increased appreciation for the fact that healthcare workers continuously ensure that most patients receive safe and high-quality care in challenging circumstances. However, despite its appeal and potential, significant challenges remain for the fruitful interpretation and application of the Safety-II perspective in healthcare, which could give rise to misinterpretations, misuse and a missed opportunity for the potential enrichment of quality and safety practices in healthcare.
  18. Content Article
    In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. 
  19. Content Article
    Recently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
  20. Content Article
    Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care.
  21. Content Article
    In this blog, Farrah Pradhan, Project Manager for Clinical Quality, Education and Projects at RCOG, describes her work with maternity professionals, namely obstetricians, and through undertaking an MSc in Patient safety. Farrah’s focus was on their 'work as done' to see if the concepts of Safety-II (capability mindfulness and resilience engineering) helped them to work more safely.
  22. Content Article
    In this 30 minute film, Adrian Plunkett introduces the concept and history of learning from from excellence. Content also includes: Safety-II Positivity language Negativity bias.
  23. Content Article
    This blog looks at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety. This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix. 
  24. Event
    This webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar
  25. Event
    After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: contact@humanisticsystems.com Register
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