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.