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Learning from incidents in health care : critique from a Safety-II perspective
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Sujan, Mark-Alexander, Huang, Huayi and Braithwaite, Jeffrey (2017) Learning from incidents in health care : critique from a Safety-II perspective. Safety Science, 99 (Part A). pp. 115-121. doi:10.1016/j.ssci.2016.08.005
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Official URL: http://dx.doi.org/10.1016/j.ssci.2016.08.005
Abstract
Patients are continually being put at risk of harm, and health care organisations are struggling to learn effectively from past experiences in order to improve the safe delivery and management of care. Learning from incidents in health care is based on the traditional safety-engineering paradigm, where safety is defined by the absence of negative events (Safety-I). In this paper we make suggestions for the policy and practice of learning from incidents in health care by offering a critique based on a Safety-II perspective. In Safety-II thinking safety is defined as an ability - to make dynamic trade-offs and to adjust performance in order to meet changing demands and to deal with disturbances and surprises. The paper argues that health care organisations might improve their ability to learn from past experience by studying not only what goes wrong (i.e. incidents), but also by considering what goes right, i.e. by learning from everyday clinical work.
| Item Type: | Journal Article | ||||||||||
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| Subjects: | R Medicine > RA Public aspects of medicine | ||||||||||
| Divisions: | Faculty of Medicine > Warwick Medical School > Health Sciences Faculty of Medicine > Warwick Medical School > Health Sciences > Social Science & Systems in Health (SSSH) Faculty of Medicine > Warwick Medical School |
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| Library of Congress Subject Headings (LCSH): | Medical care -- Safety measures , Medical personnel -- Malpractice, Physicians -- Malpractice, Nurses -- Malpractice, Organizational learning , Mid Staffordshire NHS Foundation Trust , Great Britain. National Health Service | ||||||||||
| Journal or Publication Title: | Safety Science | ||||||||||
| Publisher: | Elsevier Science BV | ||||||||||
| ISSN: | 0925-7535 | ||||||||||
| Official Date: | November 2017 | ||||||||||
| Dates: |
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| Volume: | 99 | ||||||||||
| Number: | Part A | ||||||||||
| Page Range: | pp. 115-121 | ||||||||||
| DOI: | 10.1016/j.ssci.2016.08.005 | ||||||||||
| Status: | Peer Reviewed | ||||||||||
| Publication Status: | Published | ||||||||||
| Access rights to Published version: | Restricted or Subscription Access |
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