Safety-I is defined by Professor Hollnagel as a state where as few things as possible go wrong (Hollnagel 2014). In order to achieve this ‘state’ our aim is to try to prevent things from going wrong. Being proactive and prevent harm or injury is at the very heart of risk management and safety. However, the way we do this is to ask ourselves the following questions:
How does it go wrong?
What factors contribute to things going wrong?
What did the people do to make it go wrong?
We rarely if ever ask the questions:
What happens normally?
What could we learn from that in order to understand why it failed on this occasion?
Learning from failure has laid the foundations and shaped everything about how we think about safety and how we do safety in healthcare today. This approach mirrors society where in life we pay more attention to our failures, or mistakes and the negative things that happen to us than our successes. The sad or negative events live long in our memories when the happy, positive ones can simply fade away. Consequently, negativity is considered more impactful that positivity. We are also continually told that things are getting worse, that modern life is much more negative than our past. We pay attention to these stories and it leaves us longing for different times when it felt safer and kinder and more respectful.
The problem with getting caught up in the negative is that we put more weight on failure than success. For example, let’s say I deliver a talk to ten people. In the feedback forms eight people said they loved it and two person said they hated it. What do I do? I stress about what those two people said; I am human, I want to know who they were and why they made those comments. If there is any detail associated with that feedback, I pour over it in detail. I usually ignore the other eight. Then I start to wonder if I should change the talk based on the feedback from these two people, not thinking for once that I might in fact ruin it for the eight who liked it. Let’s be honest, I would definitely change the talk based on this feedback. However, what happens if I went back and did the changed talk to the same people? What if I now have two happy people and eight unhappy listeners.
This is a little bit like the work we do in safety, we get the ‘feedback’ in the form of incident reports, investigation reports, inquiries, complaints, litigation claims and inspections. We use this feedback to change our processes, policies, training and so on. What if the changes we make actually made things worse? There are some managers, coaches and mentors who believe that it is important to point out people’s flaws to help them grow. It has never worked for me. If someone points out my flaws, I will obsess about them and blow them out of proportion. I need honest feedback, but I would rather people pointed out what I did that worked as well.
Marit de Vos describes safety 1 as learning about good marriages by only studying couples who are divorced. If you study both you will learn that a good marriage will have its flaws, ups and downs and compromises. If you study divorces, you will learn the factors that cause a marriage to fail. Put those two together and we learn about how to maintain a good marriage and spot the warning signs that could lead to it failing.
What safety I perpetuates is unequal learning. It maintains that learning from failure is better than learning from our day to day work and even our success.
We need to do both.
It is vitally important to pay attention to the failures in our care in order to improve.
It is also vitally important to put that failure in the context of normal work.
Interestingly, in many other areas of life, we study the good in order to improve. Athletes or any one who works in sport knows you need to study those who are doing well in order to perhaps replicate what they do. How did they run that fast, how did they row that well, how did they manage to hit the golf ball so far and so accurately? People want to learn from the best, those that are successful. We don’t shine a light on those that are brilliant at their jobs, those that others might want to emulate. Doing things brilliantly in healthcare is considered part of the day job. Coaches in sport aim to inspire the individual or team, build their confidence, and teach them the skills they need in order to develop and work together successfully while ensuring they feel supported along the way.
Sadly we do the opposite in healthcare.
PATIENT SAFETY NOW 