By John Tingle
Many patient safety adverse events across the National Health Service (NHS) in England have common causes, which exist regardless of clinical specialty, such as failures in communication, poor record keeping, and poor staffing levels.
This commonality of cause means that patient reports emanating from various clinical areas can have general, health system-wide value, relevance, and application. From these reports, it is possible to extrapolate generally applicable patient safety themes that can apply in a wide range of health care settings.
A recent report by the HSIB (Healthcare Safety Investigation Branch), which looks at delays to intrapartum intervention once fetal compromise is suspected, offers a case in point. Even though the focus of the report is on maternity investigations, the errors found, and the framework, methodology, and observations used in the report can have a more general application across various health care settings.
The report states that approximately 650,000 babies are born each year in England. While the vast majority are delivered safely, the report highlights some troubling trends: “when outcomes are compared to other high-income countries, there are higher numbers that are stillborn… and who die soon after birth.”
The report states that national reports over the last five years have identified this patient safety issue — delay in intrapartum intervention once fetal compromise is suspected — but that the problem still persists.
Early on in the report there is a discussion of two investigative approaches, Safety-I and Safety-II. These are different approaches that can be used to analyze the safety of systems. These approaches are drawn from the work of Erik Hollnagel, Senior Professor of Patient Safety at the University of Jönköping, Sweden. The discussion of the different approaches in the report can be applied to other patient safety problems in other areas of care, too.
Safety-I, the report states, focuses on incidents and adverse outcomes which happen when something goes wrong. The approach seeks to retrospectively understand what happened, and to rectify. Training policies, compliance, and proper procedure adoption are key aspects of this approach.
The report states that Safety-II is not focused on the minority of times when things go wrong, but rather seeks to understand how normal or routine performance results in safe outcomes, generally:
“Safety-II views safe outcomes and adverse outcomes as emerging from a same basis – that is, both types of outcome stem from everyday performance adjustments. Incidents are considered to arise from ‘unexpected combinations of everyday performance variability’ rather than being a result of ‘distinct failures and malfunctions.”
Therefore, Safety-II seeks to promote the resilience of organizations — in other words, the capacity to adjust to prevent negative variations in performance, and thus to ensure safe outcomes and prevent adverse outcomes:
“The emphasis is on improving a system’s capability to make sure things always go right, referred to as an organisation’s resilience. A key feature of a system’s potential for resilient performance is its ‘ability to adjust how it functions.’”
Both approaches have value in investigating patient safety incidents, and the report states that they are complementary to each other. However, they have differences in application and focus. The HSIB report adopts a Safety-II approach in its investigative analysis.
The report identifies the factors that are supportive of resilience, the importance of teamwork, situation awareness, multidisciplinary training, and simulation. The report emphasizes that these factors are not new, they have been highlighted in other patient safety reports.
A key value of the HSIB report is the introduction of different patient safety science approaches within the well-known clinical context of maternity care. The report also serves as a valuable patient safety teaching and learning tool.