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For many hospitals and health care systems, improving safety means being alert to things that go wrong, finding out why they happened, and fixing them. While this is a helpful approach, adding a new one aimed at anticipating errors can take patient safety to an entirely new level.

In 1999, the Institute of Medicine published “To Err Is Human.” This landmark report turned a spotlight on medical errors and the resulting harm to patients. Before the report, most physicians and hospitals assumed that errors were rare, didn’t harm patients, or were unavoidable. Once physicians and safety experts realized that these three assumptions were wrong, they began to develop ways to identify when errors occur, discover their causes, and redesign processes so the same errors didn’t occur again. This approach, called Safety I, focuses on learning from things that go wrong. It has helped hospitals become much safer.

In the complex environment of a hospital, however, some errors are due to situations that have never arisen before. For these, learning from past errors isn’t helpful in preventing the next one. To move safety efforts further forward, we need to learn from what goes right, not just what goes wrong. Being proactive at preventing errors in the first place, and learning from what goes right, is called Safety II.


Safety I sees humans as a potential liability. Available technologies are sometimes put in place to reduce the chance of human error. Such “fixes” to past errors tend to constrain or limit the actions of people. Safety II takes the opposite approach, acknowledging that humans add value because they can be proactive in figuring out what might go wrong. They are an asset because of their ability to anticipate risk before errors occur and to create innovative solutions when needed.

Safety II recognizes that health care delivery is an astoundingly complex and variable process. Even so, the vast majority of the time errors are avoided and things go well. Instead of focusing on the increasingly rare times when things go wrong, learning from how errors are avoided can be used to further improve safety.


There’s no question that Safety I has made health systems and hospitals safer (though many still need to improve their use of it). Others, though, have pushed Safety I to the limit and find that errors still occur. These are often isolated events that aren’t related to previous errors. Combining Safety I and Safety II can help.

We recognized that Safety I approaches helped us virtually eliminate adverse drug events at Nationwide Children’s Hospital. But we also observed that our pediatric intensive care unit was doing better at it than the rest of the institution. As researchers, we hypothesized that those working in the unit might be using techniques beyond Safety I, and so might be able to shine a light on what Safety II looks like in a real-world situation.

As we wrote in the journal Pediatrics, we identified factors such as a team response to challenging circumstances and skepticism when considering new ideas that led to more reliable performance, even though the pediatric intensive care unit is one of the most intense and complex microenvironments in our hospital. The Safety II approach led to that unit’s ability to handle unusual or unexpected situations while delivering high-quality care.

Safety II acknowledges that hospital systems are so complex that fixing one little piece may not make the whole system work better. It encourages incorporating innovative approaches from other areas of the hospital to improve those in which errors still need to be addressed. Of course, we need to do more testing by implementing Safety II in other hospital units to confirm that we’re on the right track before we broaden our program. For example, we plan to explore end-of-shift debriefing sessions to capture how individuals and systems respond to the unexpected and pass that learning to the next shift.

The implications of Safety II are wide-ranging. In addition to the old “finding and fixing” model of addressing errors, we now have the potential to reduce — or even eliminate — preventable harm to patients by combining Safety I and Safety II efforts.

Jenna Merandi, Pharm.D., is the medication safety officer and Thomas Bartman, M.D., is the associate medical director of quality improvement at Nationwide Children’s Hospital in Columbus, Ohio.

  • To say that retaliation and silence do not exist at your institution brings to mind the famous last words of the CEO at Dallas Presbyterian as the Ebola crisis unfolded; “We do not have systems problems!” Taking your words as your truth, you have found the “cure for cancer.” You are the only hospital in the country to not have these problems. There should be thousands of consultants from all over the world flooding your halls trying to find out how you did it. Every media outlet should have you front page news. If you read the chapter on patient safety culture in Keeping Patient’s Safe from 2003 IOM report, the highest level criteria. See if you meet all those criteria. Be an under cover boss. See what you find.

  • The problem with safety initiatives is they ignore the elephant in the room: management accountability. This is part of the normalization of deviance, to always shift the discussion away from managers. Studies indicate that managers control the culture. Nurses leave a manager. Employees would take a new boss over a pay raise. Nurses are afraid to speak up due to retaliation. Innovators and visionaries are silenced. The Cassandra syndrome? At what cost? Sadly, the one entity that could bring mass awareness to this and get the discussion going, the media, isn’t being the watchdog they should be. I have a box of unanswered emails. I’m not the only one writing. Look at the nursing blogs. Look at the comments on articles like these. Might as well be a message in a bottle.

    • We have a great deal of management accountability at NCH. The other things you describe (retaliation, silence, etc.) do not exist at this hospital. I am sorry that many places do not have the culture that we have here.

  • The authors of this article must also still sit behind a chair near the Christmas Tree on Christmas Eve night waiting to see Santa Claus. Their model for estimating medical errors is still a study done nearly twenty years ago using models that are long outmoded, and which skewed the information they did have to keep the numbers as low as possible. I applaud the study for, at least, making an attempt to reveal a problem, but the real numbers are stunningly higher and the way to address the problem has nothing to do with hospitals attempting to “guess” what will happen next. Hospitals are a villain in this story, whatever the AMA public relations people say. All of them have access to the AHRQ Common Formats program for the reporting of Medical Errors, but most of them do not use the Formats and those that do, do not make using them mandatory. Physicians are equally villainous in this dark tragedy. They not only do not report either their own errors or the errors of their colleagues, but are taught in Medical Schools and Residency Programs, “never rat on your colleagues,” as a surgeon I interviewed related to me. Off the record, of course. The authors of this article are right about one thing they said, however: the medical system is extremely complex. To entertain the idea that we are ever going to completely do away with errors that harm people is absurd. But right now the medical profession in all of it’s incarnations is killing 440,000 human beings every year in the U.S. That is more deaths than all the U.S. military losses in WWII. It is 7.5 times the total number of deaths of U.S. personnel during the entire Vietnam War (ten years of war). If you factor in the number of people who suffer “Serious Harm” from Medical Errors in the U.S. every year, the number goes up 10 – 20 times. That means 4.5 – 9 million people suffer serious harm (extended hospital stays, temporary disability and permanent disability). These numbers come from studies that examine the TRUE cause of death rather than what goes on a Death Certificate, and also compensates for the limited capabilities of a GTT when reading medical records. These are all only statistical estimates, of course, because physician do not report Medical Errors. Especially those that cause serious harm or death. TRANSPARENCY in the Medical Profession is the only way that real, tangible change will every happen in the struggle to reduce the number of people killed and maimed by it’s refusal to admit the problem. Moreover, studies have shown time and time again that most of these errors are, at least in part, by cognitive factors within the physician or medical professional. The tendency to see a problem and then MAKE AN ASSUMPTION instead of Making Sure, is a huge issue. Cognitive idiosyncrasies that go unchallenged (assumptions made) within that physicians mind instead of following a chain of logic (make sure) kill 1200 people every day.

    • Sir, your comment has nothing to do with the article we wrote above, nor the article we published in Pediatrics. Do you have something to say about Safety II? It seems your concern is about the To Err is Human report, which we only mention to indicate that medical errors are a problem (which is something you seem to agree with).

    • My comment about Safety II, Mr. Bartman, was made in my first sentence. I applaud any effort to bring a safer environment into medical facilities, but to think that one is going to raise the safety level of any hospital without the congruence and cooperation of physicians and nurses, in terms of reporting all medical errors, is like waiting for Santa Claus.

      Put these programs into place, please. Anything is better than what we have, which is chaos. Chaos created by people who feel entitled to barge through a medical situation like a bull in Pamplona, instead of like a logician in a physics lab. Medical decisions that are not acutely influenced by cognitive idiosyncrasies and short cuts are frighteningly rare and cause most harmful medical errors, which then go unreported. Cleaning up that mess is going to take a culture change, not a broom. Transparency, recognition of their own limitations and a humble sensibility by physicians must be inculcated into the medical culture.

    • Larry,

      I am sorry that your institution and others do not have the culture that you hope for. You wrote “Transparency, recognition of their own limitations and a humble sensibility by physicians must be inculcated into the medical culture.” We have that in spades at Nationwide Children’s (not just with physicians, but with all providers), which is why we are able to go beyond and look into Safety II.

      You also write that we need “congruence and cooperation of physicians and nurses, in terms of reporting all medical errors.” We have that, sir.

      Your personal attacks of us as authors (calling us naive), without knowing what things are like at NCH, are inappropriate.

      I’ll be getting back to work and not continuing a back and forth on here.

    • Mr. Bartman,

      My comments were certainly not intended to be personal to either you, your peers or your institution. They are intended to point out flaws in the Medical culture that result in preventable errors that kill people or leave them with serious disabilities. Please accept my apology for any disrespect, however unintentional, that may have been conveyed by my comments. If you have found a way that increases the safety of patients at your institution, I applaud you for it and keenly support it. In all candidness, I used the subject of your article to make a point to the Medical Profession as a whole, that desperately needs to be heard and heeded by that entity.

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