PATIENT SAFETY NOW

Despite, as I have mentioned before, a lot of enthusiasm for the concept of safety II and the mindset that it brings, there is still relatively little we know about how people can apply it in practice.

A study was published in 2025 by Roos and colleagues who described how they applied a Safety II approach to the diagnostic process in an emergency department. They directly observed 40 diagnostic processes, looking specifically at variation in everyday practice. They then took the observations into co-creation sessions with staff, identified potentially useful adaptations and implemented five changes. These included changes to pre-alert documentation, access to digital information, senior supervision, blood sampling at triage and standard blood tests. The authors explicitly say that some variations reflected resilience and adaptability, while others revealed opportunities for improvement.

This appears to pick up on the work others are doing in the world of video reflexive ethnography. Observe, identify practice including variation, understand why things are done and if necessary either leave as is or make a change.

Also in 2025 a systematic review was published https://link.springer.com/article/10.1186/s12913-025-12680-2

Birkeli and colleagues discuss the work of Professor Hollnagel in relation to the methods suggested to explore ‘work as done’ such as the Functional Resonance Analysis method (FRAM) and the Resilience Analysis Grid both of which explore the the four key areas of resilience engineering; anticipating, monitoring, responding and learning. However, the authors state that as extensive systematic literature reviews have been performed previously regarding FRAM, appreciative inquiry and positive deviance, these methods were excluded from their systematic review. Their systematic review therefore focused on tools or strategies to learn from everyday work that goes well in healthcare, thereby operationalising the Safety-II perspective. This included learning from success and work as done.

They defined a learning tool or strategy as one that supports organisational learning, and helps produce insights and inventions. The aim of the study was to provide an overview of tools for healthcare professionals to learn from work that goes well in healthcare patient safety practices. The research questions used were:

• What are the tools’ outcomes (e.g., feasibility, acceptability, effectiveness)?
• Which tools are currently practiced to learn from work that goes well in healthcare?
• Which detailed steps do the tools consist of?

If you want to explore further and test out any of these tools you can go through then link to the article (it is not behind a paywall) and you will find all the references for the tools they have noted. The tools/references are:

Learning from excellence – a voluntary reporting of episodes of excellent practice to be sent as positive feedback to the individuals involved

Save of the month – where teams are asked to identify key factors in why processes work well in particular cases, with information and ideas discussed in daily safety briefings, tested and refined by the staff doing the work

Feel forward – a way of entering information of ‘unusual’ actions in a patients electronic medical record, so that when entered the information is linked to the first page of the record which highlights to anyone else that something ‘unusual’ has been done proactively. Used to help others recognise and respond to similar patient situations in the future

Debriefing tools – used to help learn from both positive and negative aspects of an event

TALK © – a practical clinical debriefing tool underpinned by values that foster positive communication strategies; positivity, focus on finding solutions, and professional communication. TALK © consists of four steps:

• Target (What shall we discuss?)
• Analysis (What helped or hindered?)
• Learning (What can we learn from the experience?)
• Key actions (Who will follow up?)

Learning from success using simulation – learning from good performance in all simulation setting phases (pre-briefing, scenario conduct, debriefing), to be used in common everyday situations as a supplement to traditional simulation approaches

Resilience Engineering Tool to improve patient safety in anaesthesia (RETIPS-AnRes) – a tool to operationalise learning from how events go well based on reflections via a questionnaire. A case was selected that related to resilience, there was a description of the case in detail and questions such as; what went right, what were the challenges and concerns, what were the resources and area of practice

Quality assessment meetings (QAM) – A QAM is a tool used in meetings to identify how adapting behaviour led to success, despite challenging conditions

The Resilient Performance Enhancement Toolkit (RPET) – a tool to pay attention to and learn from work as done. RPET is a conversation that should take place every day, or at least every week, in safety huddles. Subjects for discussion:

• How did they recognise changes to a situation and how did they handle this?
• What happens when the same adjustments are made under different conditions?
  • To support continuous learning, items are recorded and tracked

Green line – a 5-10 min long reflection by healthcare professionals on a ward, usually in the afternoon with questions such as:

• How have you succeeded today?
• How did you manage that?

A monthly summary is then written up for others to see.

Success Tree Analysis – a tool to identify a good thing you want to happen and then, in turn, identify the things that have to happen to achieve that using a tree analysis

Extracting Safety-II Factors from an Incident Reporting System by Text Analysis – Free text data from the electronic incident reporting system was analysed using natural language processing. Text or word patterns were identified and used to note variable interactions that are positively or negatively associated with an outcome variable

Using Safety-II and resilient healthcare principles to learn from Never Events – six dimensions were used to analyse never events

Concepts for Applying Resilience Engineering (CARE) – The CARE model focuses attention on misalignments between demand and capacity, and staff adaptations in response to these misalignments and emergent outcomes. It focuses on understanding work as done in practice and how goals are achieved despite the difficulties and helps to understand the contextual factors that challenge workers

Knowledge Elicitation to Understand Resilience – An interview protocol to elicit information from frontline clinical providers about factors that underlie resilience in everyday clinical work

Resilience in the blood transfusion process: every-day and long-term adaptations to ‘normal’ work – Real-time data collection was undertaken with employees being questioned while performing each of the steps of the transfusion process. The questions were:

• Please give a short outline of the biggest or most recent difficulty that you faced when carrying out this procedure, and what did you do about it? (open response format)
• How supportive was your manager/department for how you solved the issue? (5-point Likert scale)

If anyone has used any of these tools it would be great to hear from you.