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Symposium on HF &E in Health Care 12 March 2013. Moving from Safety-I to Safety-II. Robert L Wears, MD, MS, PhD University of Florida Imperial College London. motivation. general agreement that we are not making progress on safety as fast as we would like - PowerPoint PPT Presentation
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Moving from Safety-I to Safety-II
Robert L Wears, MD, MS, PhD
University of FloridaImperial College London
Symposium on HF &E in Health Care12 March 2013
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motivationgeneral agreement that we are not making progress on
safety as fast as we would like
we have not been ‘Protestant enough’more rigour (eg, EBM)greater accountability
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motivationgeneral agreement that we are not making progress on
safety as fast as we would like
wrong mental model of safety“… enduring Enlightenment projects
“… rationality can create a better, more controllable world“… taken for granted by safety researchers b/ it appears so
ordinary, self-evident and commonsensical.”*
*Dekker 2012
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“A scientific paradigm suppresses the perception of data inconsistent with the paradigm, making it hard to perceive
anomalies that might lead to scientific revolution.”
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effect of mental models
11 year lag in discovery of Antarctic ozone hole
Meadows, Meadows, Randar 1992
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patient safety orthodoxy
technocratic, instrumental, ‘measure-and-manage’ approach
myopic – failing to question underlying nature of problems
overly simplistic – transferring sol’ns from other sectors
negligent of knock-on effects of change
“glosses over the complexities of health care organisation and delivery”
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view from safety-Iaccidents come from erratic acts by people
(variability, mistakes, errors, violations)
study, count accidents to understand safety(tend to look backwards)
focus on componentssafety is acquired by constraining workers via:
standardisation, guidelines, procedures, rules, interlocks, checklists, barriers
Taylor, Deming, ShewhartToyota
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assumptions in safety-I
our systems are well-designed and well-understoodprocedures correct and complete
systems are basically safe, well-protectedreliability = predictable, invariant
variation is the enemy safety is an attribute
(something a system has)conditions are well-anticipated, well-specified
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view from safety-IIaccidents are prevented by people adapting to conditions
study normal work to understand safety(tends to look forward)
focus on inter-relationsaim is to manage, not eliminate, the unexpected
safety is enacted by enabling workers via:making hazards, constraints, goal conflicts visible
enhancing repertoire of responses
Rasmussen, Woods, HollnagelThree Mile Island, Tenerife
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assumptions in safety-II
our designs are incomplete, procedures out-datedour systems are poorly understood
systems are basically unsafereliability = responsiveness
variation is necessary safety is an activity
(something a system does)possible failure modes have not been anticipated
‘continuing expectation of surprise’
safety-II
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healthcare STS intractable, underspecified, variable demands
resources (time, people, material, information) limited, uncertain
workers adjust to meet conditions creating variability
adjustments always approximate (b/ resources limited)
approximate adjustments usually reach goals, make things go safely
approximate adjustments sometimes fail, or make things go wrong
“Knowledge and error flow from the same mental source; only success can tell one from another.”
Ernst Mach, 1905
safety-I vs safety-II summarydefined by its opposite - failurewell designed & maintained, procedures
correct & completepeople (ought to) behave as expected &
trainedaccidents
come from variability in abovetherefore
safety comes from limiting & constraining operators via
standardization, procedures, rules, interlocks, barriers
critical inquiry
defined by its goal - successpoorly understood, incomplete,
underspecifiedpeople (ought to) adjust behaviour &
interpret proceduresaccidents
come from incomplete adaptationtherefore
safety comes from supporting operators via
making boundaries, hazards, goal conflicts visible, enhancing repertoire of responses
appreciative inquiry
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philosophical basessafety-I
linear, proportional, tractablebehaviour explained by reductionpositivist, Tayloristcause-effect simple, onewaycontrollable‘the one best way’values declarative, technical knowledgecomplicated problemstechne, episteme
safety-IInon-linear, non-proportional, intractablebehaviour explained by emergenceconstructivist, interpretivistcause-effect multiple, reciprocalinfluence-ableequifinality, multifinalityvalues practice, tacit wisdom‘wicked problems’mētis, phronesis
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why safety-II?“The real trouble with this world of ours is not that it is an unreasonable world, nor even that it is a reasonable one. The commonest kind of trouble is that it is nearly reasonable, but not quite. Life is not an illogicality; yet it is a trap for logicians. It looks just a little more mathematical and regular than it is; its exactitude is obvious, but its inexactitude is hidden; its wildness lies in wait.“
G K Chesterton, 1909
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why safety-II?
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better fit with modern theories of accidents
simple, linear, chain of events
complicated, interdependent
complex, nonlinear, coupling, resonance, emergence
why safety-II?
1940 1960 1980 2000
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why safety-II?resilience, ‘margin for maneuver’, buffers, tradeoffs all
“hidden in the interstices of complex work”
focus on how ordinary work goes right less likely to inadvertently damage these hidden resources
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empirical supportdirect observations of CV
surgerysurgeons w/ best results
had just as many untoward events as those w/ worst
but they had better means of detectiongreater repertoire of
responses
de Leval 2000
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fundamental ideas not new
Ernst Mach (1903)Charles Perrow (1984)
Jens Rasmussen (1990, 1997)Gary Klein (1989ff)
Gene Rochlin (1987, 1999)Paul Schulman (1993, 2004)
Amalberti (2001)Hollnagel et al (2006ff)
Berwick (2003)
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from st donald
Berwick, 2003
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what makes safety-I persist?
simple explanations illusion of control, ontological
securityremoves managers, organisations
from line of firefits positivist, biomedical model
‘the nurse failed to notice …’failure comes from aberrant people /
devices, so remove, control themrefitting, reorganising expensive, so
re-train insteadEnlightenment ‘program of technical
rationality’
not despite the fact that it’s wrong, but precisely because it is wrong, wrong in particularly useful ways
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why HFE is a good fit for safety-II
multiple philosophies of science admissibleexpertise in unpacking the mundane
judicious valuing of practice
‘requisite variety’ of views, toolswork as imagined vs work as done
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perceive the invisible
Insp G: Is there any point to which you would wish to draw my attention?
SH: To the curious incident of the dog in the night-time.
Insp G: The dog did nothing in the night-time.
SH: That was the curious incident …
Conan Doyle, 1893
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what is needed to move forward?
requisite varietymental models, theories, skills, people
critical masssustained co-presence
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empirical supportNSQIPS study
hospitals w/ lowest mortality had just as many
complications as those w/ worst
but they had earlier recognitionbetter responses
Ghaferi 2009
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“Any argument for the safety of a design that relies solely on pointing to what has worked successfully in
the past is logically flawed.”John Roebling
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sorting out the two views
resilience vs orthodox approachexploration vs exploitation
prescriptive vs adaptive guidancehomo- vs hetero-geneous processes
centralized vs distributed controlorganic, evolutionary vs engineered, managerial
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when HF and healthcare meet
