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Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well. [ABSTRACT FROM AUTHOR]

Abstract Background In recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Methods This study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework. Results In total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member). Conclusion The addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.

Diagnostic errors in health care are a global threat to patient safety. Researchers have traditionally focused diagnostic safety efforts on identifying errors and their causes with the goal of reducing diagnostic error rates. More recently, complementary approaches to diagnostic errors have focused on improving diagnostic performance drawn from the safety sciences. These approaches have been called Safety-II and Safety-III, which apply resilience engineering and system safety principles, respectively. This review explores the safety science paradigms and their implications for analyzing diagnostic errors, highlighting their distinct yet complementary perspectives. The integration of Safety-I, Safety-II, and Safety-III paradigms presents a promising pathway for improving diagnosis. Diagnostic researchers not yet familiar with the various approaches and potential paradigm shift in diagnostic safety research may use this review as a starting point for considering Safety-I, Safety-II, and Safety-III in their efforts to both reduce diagnostic errors and improve diagnostic performance. [ABSTRACT FROM AUTHOR]

Key content: In obstetrics and gynaecology, things often 'go well' because clinicians make sensible adaptations in response to situations to ensure safety, often within a highly pressurised environment.The adaptations and performance variables that are made under these complex circumstances are not explicitly understood.Understanding the performance variability of clinicians as well as the environmental context that enables good or successful outcomes may bring awareness of how to build adaptive capacities and capabilities in clinicians when working in unpredictable and unanticipated highly pressurised environments. Learning objectives: To be aware of the current research in safety‐II and the concept of resilience engineering in illustrating the nature of adaptations that happen in complex clinical contexts.To understand the concept of capability mindfulness, which can help clinicians to focus on their environment and to be alert and aware of correcting errors before they occur.To be aware of these concepts (behaviour and skills) through the lens of 'what went well' in clinicians' responses to unforeseen and unpredictable situations. [ABSTRACT FROM AUTHOR]

Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care. [ABSTRACT FROM AUTHOR]

Objectives The objective of this scoping review is to map methods used to study medication safety following electronic health record (EHR) implementation. Patterns and methodological gaps can provide insight for future research design. Materials and methods We used the Joanna Briggs Institute scoping review methodology and a custom data extraction table to summarize the following data: (1) study demographics (year, country, setting); (2) study design, study period, data sources, and measures; (3) analysis strategy; (4) identified limitations or recommendations; (5) quality appraisal; and (6) if a Safety-I or Safety-II perspective was employed. Results We screened 5879 articles. One hundred and fifteen articles met our inclusion criteria and were assessed for eligibility by full-text review. Twenty-seven articles were eligible for extraction. Discussion and conclusion We found little consistency in how medication safety following EHR implementation was studied. Three study designs, 7 study settings, and 10 data sources were used across 27 articles. None of the articles shared the same combination of design, data sources, study periods, and research settings. Outcome measures were neither defined nor measured consistently. It may be difficult for researchers to aggregate and synthesize medication safety findings following EHR implementation research. All studies but one used a Safety-I perspective to study medication safety. We offer a conceptual model to support a more consistent approach to studying medication safety following EHR implementation. [ABSTRACT FROM AUTHOR]

In this study, we consider the human body and the healthcare system as two complex networks and use theories regarding entropy, requisite variety, and network centrality metrics with resilience to assess and quantify the strengths and weaknesses of healthcare systems. Entropy is used to quantify the uncertainty and variety regarding a patient's health state. The extent of the entropy defines the requisite variety a healthcare system should contain to be able to treat a patient safely and correctly. We use network centrality metrics to visualize and quantify the healthcare system as a network and assign the strengths and weaknesses of the network and of individual agents in the network. We apply organization design theories to formulate improvements and explain how a healthcare system should adjust to create a more robust and resilient healthcare system that is able to continuously deal with variations and uncertainties regarding a patient's health, despite possible stressors and disturbances at the healthcare system. In this article, these concepts and theories are explained and applied to a fictive and a real-life example. We conclude that entropy and network science can be used as tools to quantify the resilience of healthcare systems. [ABSTRACT FROM AUTHOR]

Abstract Background Central to Safety-II is promoting resilience of healthcare practices. In the “Room for Resilience” research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability. Methods A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis. Results Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team’s general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work. Conclusions The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

Abstract Background The COVID-19 pandemic has presented many multi-faceted challenges to the maintenance of service quality and safety, highlighting the need for resilient and responsive healthcare systems more than ever before. This review examined empirical investigations of Resilient Health Care (RHC) in response to the COVID-19 pandemic with the aim to: identify key areas of research; synthesise findings on capacities that develop RHC across system levels (micro, meso, macro); and identify reported adverse consequences of the effort of maintaining system performance on system agents (healthcare workers, patients). Methods Three academic databases were searched (Medline, EMBASE, Scopus) from 1st January 2020 to 30th August 2022 using keywords pertaining to: systems resilience and related concepts; healthcare and healthcare settings; and COVID-19. Capacities that developed and enhanced systems resilience were synthesised using a hybrid inductive-deductive thematic analysis. Results Fifty publications were included in this review. Consistent with previous research, studies from high-income countries and the use of qualitative methods within the context of hospitals, dominated the included studies. However, promising developments have been made, with an emergence of studies conducted at the macro-system level, including the development of quantitative tools and indicator-based modelling approaches, and the increased involvement of low- and middle-income countries in research (LMIC). Concordant with previous research, eight key resilience capacities were identified that can support, develop or enhance resilient performance, namely: structure, alignment, coordination, learning, involvement, risk awareness, leadership, and communication. The need for healthcare workers to constantly learn and make adaptations, however, had potentially adverse physical and emotional consequences for healthcare workers, in addition to adverse effects on routine patient care. Conclusions This review identified an upsurge in new empirical studies on health system resilience associated with COVID-19. The pandemic provided a unique opportunity to examine RHC in practice, and uncovered emerging new evidence on RHC theory and system factors that contribute to resilient performance at micro, meso and macro levels. These findings will enable leaders and other stakeholders to strengthen health system resilience when responding to future challenges and unexpected events.

The positive deviance approach seeks to identify and learn from those that perform exceptionally well. Positive deviance as an approach to quality improvement is gaining traction in general practice. This study aimed to explore and compare stakeholders' perceptions of the factors that support the delivery of exceptional care in general practice and to refine a previously developed theoretical framework of factors associated with positively deviant care in general practice: the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Semi-structured interviews were conducted with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers in Irish general practice. Subsequently, a directed content analysis approach was employed to deductively analyse interview data using the IDEAL framework, and newly emerging factors were inductively analysed and abstracted into the framework. Several distinct strategies (e.g. patient activation and team collaboration), structures (e.g. facilities and staffing), and contextual factors (e.g. communication and rapport, and culture) were found to support the delivery of exceptional care, and differences in perceptions, values, and expectations emerged between patients and practice staff. Interview data largely supported the pre-determined factors posited by the IDEAL framework, and new factors were abstracted into the framework (e.g. facilities and infrastructure). Stakeholder engagement regarding the factors supporting exceptional care in general practice supported and extended the IDEAL framework, contributing to a more comprehensive understanding of how exceptional care is delivered in general practice. The refined framework will support researchers, policymakers, and teams looking to support, measure, and achieve exceptionally good patient care in general practice. [ABSTRACT FROM AUTHOR]

This study applied the perspective of Safety-II using the Functional Resonance Analysis Method (FRAM) and the Resilience Analysis Grid (RAG) to analyze safety in warehouse operations from a system perspective. FRAM was used to emphasize what caused things to go right, with the findings highlighting higher performance and safety variability occurring in activities that require multiple individual or group efforts. RAG was used to assess the organization's potential to handle unexpected occurrences, identify the potential resilience of the warehouse in its daily activities, and evaluate the ability to maintain flow and worker safety based on four pillars of resilience. The assessment resulted in a value of 3.50 in the ability to respond, 2.84 in the ability to monitor, 3.88 in the ability to learn, and 3.21 in the ability to anticipate. Combining FRAM and RAG enhances the depth of a new perspective of safety analysis and addresses resilience factors in daily operations. [ABSTRACT FROM AUTHOR]

Background: Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability. Methods: A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis. Results: Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work. Conclusions: The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has presented many multi-faceted challenges to the maintenance of service quality and safety, highlighting the need for resilient and responsive healthcare systems more than ever before. This review examined empirical investigations of Resilient Health Care (RHC) in response to the COVID-19 pandemic with the aim to: identify key areas of research; synthesise findings on capacities that develop RHC across system levels (micro, meso, macro); and identify reported adverse consequences of the effort of maintaining system performance on system agents (healthcare workers, patients). Methods: Three academic databases were searched (Medline, EMBASE, Scopus) from 1st January 2020 to 30th August 2022 using keywords pertaining to: systems resilience and related concepts; healthcare and healthcare settings; and COVID-19. Capacities that developed and enhanced systems resilience were synthesised using a hybrid inductive-deductive thematic analysis. Results: Fifty publications were included in this review. Consistent with previous research, studies from high-income countries and the use of qualitative methods within the context of hospitals, dominated the included studies. However, promising developments have been made, with an emergence of studies conducted at the macro-system level, including the development of quantitative tools and indicator-based modelling approaches, and the increased involvement of low- and middle-income countries in research (LMIC). Concordant with previous research, eight key resilience capacities were identified that can support, develop or enhance resilient performance, namely: structure, alignment, coordination, learning, involvement, risk awareness, leadership, and communication. The need for healthcare workers to constantly learn and make adaptations, however, had potentially adverse physical and emotional consequences for healthcare workers, in addition to adverse effects on routine patient care. Conclusions: This review identified an upsurge in new empirical studies on health system resilience associated with COVID-19. The pandemic provided a unique opportunity to examine RHC in practice, and uncovered emerging new evidence on RHC theory and system factors that contribute to resilient performance at micro, meso and macro levels. These findings will enable leaders and other stakeholders to strengthen health system resilience when responding to future challenges and unexpected events. [ABSTRACT FROM AUTHOR]

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces. [ABSTRACT FROM AUTHOR]

• A systematic literature review is undertaken to identify the main constructs of leading indicators (both passive leading indicators and active leading indicators). • Interpretivism and critical realism philosophical stances are utilised together with inductive reasoning to generate new perspectives and insight in leading indicators. • A culmination of research conducted leads to the generation of a guidance note for leading indicator implementation (as a conceptual model). • Notably, the model proposes continuous learning through a perpetual loop of development and application of leading indicators in the workplace. Introduction: Leading indicators represent an invaluable tool that offer organizations the capability to: track health and safety performance, not just failures and accidents; measure effectiveness of safety efforts adopted; and focus on undesired precursors, rather than undesired occurred events. Despite these palpable advantages associated with their adoption, leading indicator's definition, application, and function are mostly ambiguous and inconsistent within literature. Therefore, this study systematically reviews pertinent literature to identify the constructs of leading indicators and generates guidance for leading indicator implementation (as a conceptual model). Method: The overarching epistemological design adopted interpretivism and critical realism philosophical stances together with inductive reasoning to analyze 80 articles retrieved from the Scopus database, plus 13 more publications supplemented by the snowballing technique. Analysis of the safety discourse within literature (as secondary data) was undertaken in two stages, namely: (1) a cross-componential analysis identified the main features of leading indicators in comparison to lagging indicators; and (2) content analysis revealed prominent constructs of leading indicators. Results and conclusion: Analysis results identify that the definition, types, and development methods represent the main constructs for understanding the concept of leading indicators. The study identifies that ambiguity around the definition and function of leading indicators is due to the lack of differentiation of its types, namely passive leading indicators and active leading indicators. Practical application: As a practical contribution, the conceptual model, which introduces continuous learning through a perpetual loop of development and application of leading indicators, will help adopters create a knowledge repository of leading indicators and to continuously learn and improve their safety and safety performance. Specifically, the work clarifies their difference in terms of the timeframe passive leading indicators and active leading indicators take to measure different safety aspects, the functions they serve, the target they measure and their stage of development. [ABSTRACT FROM AUTHOR]

Aim: To describe factors that prevent patient safety incidents in connection with the radiological examination from the radiographer's perspective. Background: Radiology plays an important role in the care chain and involves diagnostic examinations and treatments using various radiation sources and different techniques. Risks for patient safety incidents exist in every phase of a radiological examination. Appropriate use of medical imaging requires a multidisciplinary approach involving staff of different categories to meet the medical objectives and the patient's care needs. In accordance with a Safety‐II approach, it is therefore important to understand why things go right and ensure that they do by supporting the conditions for right things to happen. Design: A qualitative study with a descriptive design. Methods: Semi‐structured interviews were conducted with 17 radiographers. The data were analysed using theoretical thematic analysis based on the Systems Engineering Initiative for Patient Safety model. Results: The analysis yielded 20 sub‐themes, which describe different success factors contributing to patient safety. Conclusion: Proactive work should focus on collaboration and sharing the necessary knowledge, internally and externally, for care in connection with the radiological examination. The radiological and peri‐radiographic knowledge should include monitoring the patient's safety needs before, during and after the radiological examination. The referring clinician has a central role in writing relevant referrals and the radiographer's competence is crucial in monitoring the patient's safety needs. A good patient safety culture is required and working with standards is important. [ABSTRACT FROM AUTHOR]

Background: Workflow interruptions in pharmacies contribute to dispensing errors, a high-priority issue in patient safety, but have rarely been studied from a systemic perspective partly because of the limitations of the conventional reductionistic approach. This study aims to identify a mechanism for the occurrence of interruptions in a hospital pharmacy and find interventional points using a synthetic approach based on resilience engineering and systems thinking, and assess implemented measures for reducing them. Methods: At a Japanese university hospital, we gathered information about performance adjustments of pharmacists in the inpatient medication dispensing unit for oral and topical medicines (IMDU-OT) and nurses in the inpatient wards (IPWs) in the medication dispensing and delivery process. Data about the workload and workforce of pharmacists were collected from hospital information systems. Telephone inquiries and counter services in the IMDU-OT, the primary sources of interruptions to pharmacists' work, were documented. The feedback structure between the IMDU-OT and the IPWs was analyzed using a causal loop diagram to identify interventional points. The numbers of telephone calls and counter services were measured cross-sectionally before (February 2017) and four months after implementing measures (July 2020). Results: This study found that interruptions are a systemic problem emerging from the adaptive behavior of pharmacists and nurses to their work constraints, such as short staffing of pharmacists, which limited the frequency of medication deliveries to IPWs, and lack of information about the medication dispensing status for nurses. Measures for mitigating cross-system performance adjustments—a medication dispensing tracking system for nurses, request-based extra medication delivery, and pass boxes for earlier pick-up of medicines—were introduced. Following their implementation, the daily median number of telephone calls and counter services was significantly reduced (43 to 18 and 55 to 15, respectively), resulting in a 60% reduction in the total number of interruptions. Conclusion: This study found interruptions in the hospital pharmacy as a systemic problem that can be reduced by mitigating difficulties being compensated for by clinicians' cross-system performance adjustments. Our findings suggest that a synthetic approach can be effective for solving complex problems and have implications for methodological guidance for Safety-II in practice. [ABSTRACT FROM AUTHOR]

Abstract Background To reduce patient harm, healthcare has focused on improvement based on learning from errors and adverse events (Safety-I). Daily huddles with staff are used to support incident reporting and learning in healthcare. It is proposed that learning for improvement should also be based on situations where work goes well (Safety-II); daily safety huddles should also reflect this approach. A Safety-II-inspired model for safety huddles was developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden. This study followed the implementation with the research questions: Do patient safety huddles with a focus on Safety-II affect the results of measurements of the patient safety culture? What are the experiences of these huddles amongst staff? What experiences of everyday work arise in the patient safety huddles? Methods A multi-method approach was used. The quantitative part consisted of a questionnaire (151 items), submitted on four different occasions, and analysed using Mann Whitney U-test and Kruskal Wallis ANOVA-test. The qualitative data were analysed using thematic content analyses of interviews with staff (n = 14), as well as answers to open questions in the questionnaires. Results There were 151 individual responses to the questionnaires. The response rates were 44% to 59%. For most comparisons, there were no differences. There were minor changes in patient safety culture measurements. A lower rating was found in December 2020, compared to October 2019 (p

Safety-II is a recently theorized approach, considering safety as the ability of a system to reach a positive outcome under variable conditions: analyzing "what goes right" can help to understand the dynamics of the analyzed system and improve its inherent safety level. On the contrary, a more traditional perspective, defined as Safety-I, aims at analyzing "what goes wrong", thereby relating the safety level of a system to the number of adverse events that occurred. This study explores the potentialities of integrating these two approaches in near-miss management. Through a Safety-I approach, near-miss events are analyzed to identify the root causes generating the event chain, in order to delete them and prevent future accidents. Applying a Safety-II approach, the analysis can include elements that contributed to limiting the consequences and blocking the event chain, revealing the resilience level of the systems. This study presents a critical analysis of the two approaches and proposes a practical framework to integrate them into near-miss management systems. A test case shows the potential benefits of this integration. This work provides a tool to support the implementation of Safety-II on the operative level while suggesting a new perspective for near-miss management. [ABSTRACT FROM AUTHOR]

Historical and current methodologies in patient safety are based on a deficit‐based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit‐based approach has some theoretical limitations. In this article, we discuss some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety‐II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system‐wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success—both outstanding success and everyday success—including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety. [ABSTRACT FROM AUTHOR]

Background: Limitations of traditional structures and approaches to further enhance patient safety, satisfaction, and systemic sustainability in healthcare, are becoming increasingly visible. Embedding reflexivity is a proposed strategy to promote progress. We aimed to explore the potential of creating reflexive spaces for promoting integration and client-centeredness in maternity care specifically., Methods: In this participatory action research (PAR), two multidisciplinary and multiorganizational groups of maternity care professionals and clients (n = 28) from two Dutch regions, participated in 'reflexive dialogues'. Cases were discussed from a Safety-II perspective. In total, 22 meetings took place from 2020-2022, mostly online. Additionally, 23 participants were interviewed. Data were audio-recorded, transcribed, and thematically analyzed., Findings: Participants were generally positive about the reflexive dialogues and Safety-II approach. They felt both safe and challenged to critically reflect on their own and each other's care practices. Exchanging perspectives, experiences, and approaches fostered trust, well-being, and repertoire, and through this, resilience., Conclusions: By structurally stimulating, facilitating, and embedding Safety-II guided reflexive dialogues between professionals and clients from multiple organizations and disciplines, healthcare leaders could promote resilience and reinforce the transformation towards integrated, relation-centered maternity care., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Abstract Background Healthcare professionals are sometimes forced to adjust their work to varying conditions leading to discrepancies between hospital protocols and daily practice. We will examine the discrepancies between protocols, ‘Work As Imagined’ (WAI), and daily practice ‘Work As Done’ (WAD) to determine whether these adjustments are deliberate or accidental. The discrepancies between WAI and WAD can be visualised using the Functional Resonance Analysis Method (FRAM). FRAM will be applied to three patient safety themes: risk screening of the frail older patients; the administration of high-risk medication; and performing medication reconciliation at discharge. Methods A stepped wedge design will be used to collect data over 16 months. The FRAM intervention consists of constructing WAI and WAD models by analysing hospital protocols and interviewing healthcare professionals, and a meeting with healthcare professionals in each ward to discuss the discrepancies between WAI and WAD. Safety indicators will be collected to monitor compliance rates. Additionally, the potential differences in resilience levels among nurses before and after the FRAM intervention will be measured using the Employee Resilience Scale (EmpRes) questionnaire. Lastly, we will monitor whether gaining insight into differences between WAI and WAD has led to behavioural and organisational change. Discussion This article will assess whether using FRAM to reveal possible discrepancies between hospital protocols (WAI) and daily practice (WAD) will improve compliance with safety indicators and employee resilience, and whether these insights will lead to behavioural and organisational change. Trial registration Netherlands Trial Register NL8778; https://www.trialregister.nl/trial/8778 . Registered 16 July 2020. Retrospectively registered.

Background: To reduce patient harm, healthcare has focused on improvement based on learning from errors and adverse events (Safety-I). Daily huddles with staff are used to support incident reporting and learning in healthcare. It is proposed that learning for improvement should also be based on situations where work goes well (Safety-II); daily safety huddles should also reflect this approach. A Safety-II-inspired model for safety huddles was developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden. This study followed the implementation with the research questions: Do patient safety huddles with a focus on Safety-II affect the results of measurements of the patient safety culture? What are the experiences of these huddles amongst staff? What experiences of everyday work arise in the patient safety huddles?Methods: A multi-method approach was used. The quantitative part consisted of a questionnaire (151 items), submitted on four different occasions, and analysed using Mann Whitney U-test and Kruskal Wallis ANOVA-test. The qualitative data were analysed using thematic content analyses of interviews with staff (n = 14), as well as answers to open questions in the questionnaires.Results: There were 151 individual responses to the questionnaires. The response rates were 44% to 59%. For most comparisons, there were no differences. There were minor changes in patient safety culture measurements. A lower rating was found in December 2020, compared to October 2019 (p < 0.05), regarding whether the employees pointed out when something was about to go wrong. The interviews revealed that, even though most respondents were generally positive towards the huddles (supporting factors), there were problems (hindering factors) in introducing Safety-II concepts in daily safety huddles. There was a challenge to understanding and describing things that go well.Conclusions: For patient safety huddles aimed at exploring everyday work to be experienced as a base for learning, including both negative and positive events (Safety-II); there is a need for an open and permissive climate, that all professions participate and stable conditions in management. Support from managers and knowledge of the underpinning Safety-II theories of those who lead the huddles, may also be of importance. [ABSTRACT FROM AUTHOR]

Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like represent a lack of safety rather than the presence of safety. To explain this lack of safety, one or more causes must be found. In the management of industrial safety, the human factor has traditionally been seen as a weak element; human error is often offered as the first, and sometimes the only cause of lack of safety and human factors have since the early days offered three principal solutions, namely training, design, and automation. Of these, training has considerable face value as an effective means to improve human performance. The drawback of safety training, however, is that it focuses on a single system component, the human, instead of on the system as a whole. Safety training further takes for granted that humans are a liability and focuses on overcoming the weakness of this specific component through simplistic models of what determines human performance. But humans may also be seen as an asset which changes the focus to strengthening how a complex socio-technical system functions. A socio-technical system comprises multiple functions that must be finely tuned in order to ensure expected and acceptable performance. Since systems cannot be made safer without developing effective ways of managing the conditions in which people work, system tuning offers an alternative solution to an old problem.

This paper discusses the role of human performance variability in ship-to-ship collisions. Accordingly, an analysis was carried out based on the functional resonance analysis method (FRAM). A ship-to-ship collision report from Indonesia was used to generate the FRAM model for ship-ship encounters. This model was formed using six functions: maneuvering, watchkeeping, bridge communication, bridge-to-bridge communication, bridge-to-port communication, and engine control. Using FRAM, the cause of the collision accident can be determined based on the results of this analysis. This study emphasizes that the emergence of unwanted outcomes results from the unique interaction of the unexpected variability performance of functions between two ships during encounter situations. The resonance phenomenon explained how this unique interaction amplifies the effect of ship operation, performance variability. The use of FRAM could elucidate the complexity in ship operation and provide a more in-depth analysis for ship-to-ship collision accidents.

Background: Traditional safety concept, which is called Safety-I, and its relevant methods and models have much contributed toward enhancing the safety of industrial systems. However, they have proved insufficient to be applied to complex socio-technical systems. As an alternative, Safety-II and resilience engineering have emerged and gained much attention for the last two decades. However, it seems that safety professionals have still difficulty understanding their fundamental concepts and methods. Accordingly, it is necessary to offer an introductory guide to them that helps safety professionals grasp them correctly in consideration of their current practices. Methods: This article firstly explains the limitations of Safety-I and how Safety-II can resolve them from the four points of view. Next, the core concepts of resilience engineering and Functional Resonance Analysis Method are described. Results: Workers' performance adjustment and performance variability due to it should be the basis for understanding human-related accidents in socio-technical systems. It should be acknowledged that successful and failed work performance have the same causes. However, they are not well considered in the traditional safety concept; in contrast, Safety-II and resilience engineering have conceptual bases and practical approaches to reflect them systematically. Conclusion: It is necessary to move from a find-and-fix and reactive approach to a proactive approach to safety management. Safety-II and resilience engineering give a set of useful concepts and methods for proactive safety management. However, if necessary, Safety-I methods need to be properly used for situations where they can still be useful as well.

Abstract Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work. A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.

• Systematic review of 33 papers on participation in construction. • Knowledge framework for the design of participatory practices. • 7 design meta-principles, 7 design principles, and 17 design prescriptions. • Participation's contribution to safe and resilient construction projects. • Participatory practices can contribute to both Safety-I and Safety-II. Workers' participation has long been acknowledged as a means for the harmonization of the technical and social components of socio-technical systems. However, guidance to designers of participatory practices is often implicit in the literature, which also does not jointly address safety and resilient performance, two key business aspects in construction projects. This paper addresses these gaps by proposing a knowledge framework for the design of participatory practices that contribute to safe and resilient construction projects. To this end, a systematic literature review of 33 papers on participation in construction was carried out. Based on a thematic analysis, this review gave rise to a framework composed of seven design meta-principles, seven design principles, and 17 design prescriptions. The seven principles mediate the relationships between the more abstract meta-principles and the more operational prescriptions. The framework encompasses dimensions of participatory practices that can contribute for the design of resilient systems and for the operationalization of both safety-I and safety-II in construction. [ABSTRACT FROM AUTHOR]

Abstract Background Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC. Methods Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach. Results Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care ‘resilience’ training of health care professionals were factors used to develop RHC. Conclusions Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

Background: Healthcare professionals are sometimes forced to adjust their work to varying conditions leading to discrepancies between hospital protocols and daily practice. We will examine the discrepancies between protocols, 'Work As Imagined' (WAI), and daily practice 'Work As Done' (WAD) to determine whether these adjustments are deliberate or accidental. The discrepancies between WAI and WAD can be visualised using the Functional Resonance Analysis Method (FRAM). FRAM will be applied to three patient safety themes: risk screening of the frail older patients; the administration of high-risk medication; and performing medication reconciliation at discharge.Methods: A stepped wedge design will be used to collect data over 16 months. The FRAM intervention consists of constructing WAI and WAD models by analysing hospital protocols and interviewing healthcare professionals, and a meeting with healthcare professionals in each ward to discuss the discrepancies between WAI and WAD. Safety indicators will be collected to monitor compliance rates. Additionally, the potential differences in resilience levels among nurses before and after the FRAM intervention will be measured using the Employee Resilience Scale (EmpRes) questionnaire. Lastly, we will monitor whether gaining insight into differences between WAI and WAD has led to behavioural and organisational change.Discussion: This article will assess whether using FRAM to reveal possible discrepancies between hospital protocols (WAI) and daily practice (WAD) will improve compliance with safety indicators and employee resilience, and whether these insights will lead to behavioural and organisational change.Trial Registration: Netherlands Trial Register NL8778; https://www.trialregister.nl/trial/8778 . Registered 16 July 2020. Retrospectively registered. [ABSTRACT FROM AUTHOR]