O T H E R F E AT U R E S “What Goes Wrong” (Safety-I) and “What Goes Right” (Safety-II) In our efforts to optimize the safety of healthcare, is preventing “things that go wrong” a sufficient strategy? Many, if not all, healthcare safety programs focus on understanding what went wrong when an adverse event affects a patient. In seeking to prevent the possible recurrence of adverse events, there has been a cultural movement away from a “name, shame, and blame” process1 and toward a search for multiple underlying contributory causes.2 Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS Investigative processes such as root-cause analysis (RCA) are intended to retrospectively Editor, Pennsylvania Patient Safety Advisory identify—and potentially provide an opportunity to mitigate—conditions or circumstances Medical Director, Pennsylvania Patient Safety Authority that may have contributed to an adverse event. Exploration of a comprehensive list of contributing causes is an important part of the RCA process, and a variety of methods, such as Ishikawa’s Fishbone or the 5 Whys, have been advocated.3 The RCA process appeals to our understandable desire to “tame risk and uncertainty.”4 RCA meetings typically involve multiple diverse stakeholders; participation creates “an opportunity for improved communication in the workplace through organized sense making.”4 Hollnagel and others label this approach as “Safety-I”—a reactive approach to under- standing what factors may have contributed to an undesired outcome.5 Typically, infrequent events that involve the greatest harm receive the most attention. There is a complementary approach, “Safety-II,” which additionally seeks to understand “what goes right,” including what goes right during ordinary healthcare delivery.5 Proactive attention is paid to understanding how healthcare that works is actually accomplished. Safety-II focuses on trying to anticipate developments and events. The Safety-II perspec- tive explores what goes right to make sure that as much as possible will go right in the complex, sometimes unpredictable environment of healthcare delivery.5 For example, in addition to analyzing what goes wrong in patient care units with high rates of certain events (e.g., falls, infections), Safety-II also looks at the many more events that turn out right to understand what makes for successful work. Additionally, it may also be worth- while to evaluate patient care units that have low rates of undesired events. What do they do that might be different? Have they eliminated hazardous processes or materials, or implemented design controls (such as engineering controls based on human factors principles) or administrative controls that have resulted in improvements?6 Simulation is one resource that can be used to improve our understanding of both what goes wrong and what goes right. A simulation scenario can re-create common or uncommon healthcare situations; participants from multiple disciplines respond and collaborate to manage a simulated patient together. A simulation can also show how people adjust their performance to the conditions, resources, and demands of health- care delivery. In addition to providing practice to improve the teamwork and probably the sense making of the healthcare providers, during the subsequent debriefing or guided reflection, participants can articulate and reinforce helpful activities as well as identify opportunities for improvement. These improvements may involve actions, equipment, processes, or other aspects of the patient care process. Although many simulations are based on real events, the simulation itself does not include direct risk or adverse outcomes for real patients.7 Skilled facilitation helps participants reflect on the patient care process in a constructive and supportive manner. Hollnagel and others suggest that humans, rather than being liabilities or hazards, are necessary resources that provide system flexibility and resilience.5 Many organizations understand the value of rewarding “good catches” by healthcare providers, support services personnel, or other organizational staff. The Pennsylvania Patient Safety Authority recognizes individuals and groups within Pennsylvania healthcare facilities Vol. 12, No. 2—June 2015 Pennsylvania Patient Safety Advisory Page 83 ©2015 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S who have demonstrated a personal com- Beyond celebrations, there may also be occur. Safety-I and Safety-II are comple- mitment to patient safety, including lessons to be learned from studying frequent mentary; both perspectives can add to our acknowledgment during the annual I Am events in which there was a “good catch,” understanding of how to improve the safety Patient Safety campaign (see http:// just as lessons may be learned by studying of healthcare delivery. patientsafetyauthority.org/NewsAnd events in which undesired outcomes Information/PressReleases/2015/Pages/ pr_March_5_2015.aspx). NOTES 1. Tevlin R, Doherty E, Traynor O. Improv- 4. Cassin BR, Barach PR. Making sense 6. Card AJ, Ward J, Clarkson PJ. Success- ing disclosure and management of of root cause analysis investigations of ful risk assessment may not always lead medical error - an opportunity to trans- surgery-related adverse events. Surg Clin to successful risk control: A systematic form the surgeons of tomorrow. Surgeon North Am 2012 Feb;92(1):101-15. literature review of risk control after 2013 Dec;11(6):338-43. 5. Hollnagel E, Wears R, Braithwaite J. root cause analysis. J Healthc Risk Manag 2. Dew JR. In search of the root cause. Qual From Safety-I to Safety-II: a white paper 2012;31(3):6-12. Prog 1991 Mar;24(3):97-102. [online]. 2015 [cited 2015 Apr 25]. 7. Deutsch ES. Simulation in otolaryn- 3. Karl R, Karl MC. Adverse events: root http://resilienthealthcare.net/oneweb gology: smart dummies and more. causes and latent factors. Surg Clin North media/WhitePaperFinal.pdf Otolaryngol Head Neck Surg 2011 Am 2012 Feb;92(1):89-100. Dec;145(6):899-903. Page 84 Pennsylvania Patient Safety Advisory Vol. 12, No. 2—June 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 2—June 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. 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