Three models of safety

There is a recognition that strategies for managing safety in highly standardised and controlled environments such as radiotherapy are necessarily different from those in which clinicians and others constantly have to adapt and respond to the changing circumstances they are faced such as the emergency department of a general practice in the community.  Because of this variability Vincent and Amalberti (2016) provide really helpful suggestions in relation to the variety of safety strategies and interventions.

The three models of safety

The three models summarised by Vincent and Amalberti (2006) are:

1. Ultra adaptive – Embracing risk – Taking risks is the essence of the profession.  The model required is that of experts who rely on personal resilience, personal expertise and technology to survive and prosper in the adverse conditions
2. High Reliability – Managing risk – Risk is not sought out but is inherent in the profession.  The model required is that of the devolved groups who can organise themselves, provide mutual support, and who are allowed to adapt and make sense of their environment
3. Ultra safe – Avoiding risk – Risk is excluded as far as possible.  The model lends itself to regulation and supervision of the system to avoid exposing frontline staff and patients to unnecessary risk

The authors’ view is that we need to distinguish the three models approve to the management of risk each with its own characteristic approach.  Each one gives rise to a way of organising safety with its own characteristic approach and its own possibilities of improvement (Vincent and Amalberti 2016).  The authors also provide a new and broader vision for addressing patient safety that encompasses care throughout the patient’s journey including care at home.  It helps us also study how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast.

The three models in relation to healthcare

• Examples of an ultra-adaptive environment are emergency medicine or community general practice (GPs).  These are areas that have a very high level of autonomy.  Becoming safer is about helping people adapt and respond to the difficult situations they face.  It is also about recognising that emergency medicine and other ultra-adaptive environments will never be free from harm.  These are the areas where prescribing care is very hard to do and people need to be trusted to constantly adapt and adjust what they do.
• Examples of a high reliability system are scheduled surgery, obstetrics and midwifery.  These areas are reliant on personal skill and resilience but in a more prepared and disciplined way.  The risks while not entirely predictable are known and understood.  I these areas risk management is a constant concern.  Just to note that high reliability organisations as a concept have been considered for a few years now with organisations aiming to detect and respond to risk more proactively.  These are the areas that need some prescribing but also need to be able to adapt when needed.  For example, the induction of anaesthesia in the operating room needs to follow a clear sequence of activities and decisions reliably every time.
• Examples of an ultra-safe system are blood transfusion, microbiology, and radiotherapy.  These areas are reliant on standardisation, automation and the avoidance of risk wherever possible.  The skills required in these areas are knowledge and execution of standard operating procedures and practiced routines.  This approach also relies on external oversight, rules and regulation.  These are the areas that lend themselves to prescribing care and do require as much detail as possible to be written down.  For example the delivery of chemotherapy requires a high degree of accuracy in terms of the amount prescribed and a clear adherence to rules around prescribing and administration.

However, like all things there is no such thing as a one size model for patients who are subjected to all three of these models, sometimes within the same healthcare ‘admission’.  For example a patient who is in a road traffic accident will be treated by paramedics and the ambulance service who will need to respond in an ultra-adaptive way.  The patient will need to be assessed, diagnosed and treated in accordance with not only what has happened to them but where it has happened.  The patient will then be transported to the emergency department who will also need to react to the patient’s condition which will change over time.  The patient may require surgery and then they get to experience the ultra-adaptive system of anaesthesiology and surgery together with post-operative recovery and ward care.  During their time in hospital they may be given a blood transfusion and will undoubtedly be tested and if necessary treated for infection and electrolyte imbalance which require an ultra-safe system.  The patient may have needed resuscitation and defibrillation which also require an ultra-safe system of administration in terms of the right amount of medication and administration of shock.

Underpinning these models is the system migration concepts by Rene Amalberti.  His work on system migration is an extremely influential model for safety and helps us understand in particular violations.  Violations are described as times when people don’t follow the rules and standards – deviations from the instructions.  There are many reasons why violations happen and Amalberti describes the gradual shift to the ‘boundary of safety’ and it combines a dynamic systems view of safety and risk with the psychological appreciation of the behavioural drivers underlying violations (Vincent et al 2013).

Amalberti describes how deviations from instructions may become normalised and how we can go from the working safely to being more risky and then even further.  An example often used is driving.  We all know in the UK we are supposed to drive on motorways (freeways) at a maximum speed of 70 miles per hour, but occasionally people shift into a risky speed of around 70 to 75 (described as ‘illegal normal’) but then even more rarely people may increase their risky behaviour by driving at around 80 miles per hour, and in some very miner occurrences some people may go much higher than this (illegal-illegal).  We shift our behaviour because of demand, external pressures, individual and social forces.  In healthcare Amalberti suggests it is likely to be between less than 1% and 5% of people who take extreme risks, or are reckless in their behaviour.