For over a decade, the language and narrative of safety has been trying to embrace the concepts of a ‘new approach’, mainly called Safety I and Safety-II or Safety Differently. It has circulated through healthcare conferences, academic journals, and policy discussions. Influential thinkers such as Erik Hollnagel, Sidney Dekker, Stephen Shorrock and Jeffrey Braithwaite (and many others) have challenged us to rethink safety. Not as the absence of harm, but as the presence of safety.
I have been a big fan ever since listening to Erik Hollnagel talk at a conference in Exeter one year. I even titled my first book ‘Rethinking Patient Safety’. I felt that this new ideology and the concepts associated with safety II was transformative and reminded me of the exciting early days of safety around the turn of the century when safety was all about understanding flow, environmental factors, how people worked and what we could do to help them.
Sadly it was not long after those early days when safety became synonymous with incident reporting, investigations and compliance. The joy of safety was lost and it became a stick with which to beat people up with. I always felt like there was something missing, that there was so much more we could do. Erik Hollnagel showed me another way. I literally changed my thinking on safety after one talk. Not many people can do that.
Enthusiasm but no traction
However, despite the thinking having been around for over a decade, as someone said to me recently at a conference, why has it not really gained traction, why has this new approach not yet taken hold in the way many anticipated. Often when I ask a non-safety audience if they have heard of safety I and safety II no one raises their hand. It just isn’t something they have come across.
Of course there are many reasons for this, change literature, implementation science and other key areas of research can provide us with a long list of factors that can tell us why things struggle to be implemented. The known gap between theory and practice. We have also obviously had an overwhelmingly difficult period in healthcare that has impacted on staff profoundly and their ability to absorb anything new is virtually nil.
But one thing I have noticed over the last few years is that by talking about it as a ‘new approach’, and putting names to it such as Safety I, (what we do now) and Safety II (what we do differently) it has created the feeling there is a distinct difference between our current approach and what we could do differently. It has created distance rather than engagement.
Having the new names helps to explain it, helps to simplify it a bit and it does engage people in the beginning. In fact, the concepts are warmly and often enthusiastically grasped whenever I talk to anyone who works in healthcare. However, there is usually one or two who think that it is more work, a new initiative, something to add on to what they already are expected to do. And I think that when the enthusiasts leave the conference or workshop they too start to wonder how they could actually use this approach in their everyday.
For many working in healthcare they are already on their knees, why do they need something else that adds to this strain. Also, it can, if not careful, feel like they are being told that everything they have been doing for decades is somehow insufficient or worse has been a waste of time. This is particularly true for those that work in risk or safety.
So the response is conceptual agreement but ultimately limited take up. A new approach becomes something to discuss wistfully, rather than something to do practically. Sadly with not that many examples of how it has been successfully implemented it is hard to show that safety II actually works.
What matters to staff
The areas that really resonate when I talk to staff, clinicians in particular, is the fact that their everyday clinical work is all about constantly adapting to changing conditions. They anticipate problems, adjust workflows, create workarounds, and recover from disruptions. Teams coordinate under pressure, often really successfully, despite the system constraints they work in. Most of the time things go ok. But in safety we are often led to believe that it is the opposite that most of the time things fail.
Therefore when I talk about how what we should be doing is focusing on understanding the work they do everyday to maintain safety, to understand how hard it is to do their work and to understand the near misses and the early warning signals that tell us how the system is functioning. They love this.
But we have struggled to find ways of doing this and over time it has become an after thought. “Why would we study things that are going ok, we have enough work to do to study when it fails”. But it is so important to study when it fails and when it succeeds. It is important that we show staff that we care about the conditions they work in and want to understand what it is like and what we could do to help.
Winning hearts and minds
In the google study project Aristotle, they asked 250 of their teams to name the factors that helped build high performing teams. Two of those were meaning of work and impact of work. Any approach to safety should be about helping create the feeling that what they do matters. The work we do to maintain safety should resonate with clinicians, managers, and leaders. It must feel familiar, useful, and credible—not abstract or imposed. This is as much a relational and cultural challenge, as a technical one. Fundamentally, it is about:
- trust in frontline expertise
- curiosity about everyday work
- understanding the complexity and different systems in healthcare and how they impact on risk and peoples ability to maintain safety
- building a psychologically safe environment for people to belong, learn, grow, contribute and challenge
- responding with a culture that is both just and restorative
Truly understanding how healthcare practitioners are able to keep patients safe, despite the conditions they work in.
Rethinking safety – a new mindset
So, as I have mentioned, I think one of the key issues is that the new approach has been positioned as something different. The way forward is to show that it is not actually a new model of safety, it is a description of how safety already happens, a new mindset, not an extra layer onto existing work.
We need more evidence of how the concepts can be embedded easily into our current approach to safety. The global literature reflects a little of this. There are pockets of implementation, use of tools such as FRAM by a few specialists, or resilience-informed investigations, and reflective practices—but these remain localised and often research-led.
In order for the ideas to reshape how we think it might mean:
- Talking less about “Safety-II” and more about how work is actually done, how safety is maintained
- Shifting conversations from “what went wrong” to “why did it fail this time when it normally goes ok” and “how did this usually go right?”
- Designing learning systems that explore success as rigorously as failure
- Recognising frontline adaptability as a core safety resource, not something to punish.
- Talking about safety, not as compliance, not as the absence of harm, but as the ongoing achievement of successful work under varying conditions. Doing this in order to reduce risk where we can, prevent harm and failure, create the conditions for safety to succeed.
By absorbing the ideology of safety II into the fabric of how healthcare understands safety, we may finally achieve what it always promised: a much kinder, compassionate and positive approach to safety.
PATIENT SAFETY NOW 
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