The bionomic approach to patient safety and its application in gynaecological surgery

In the past 2 decades, a gradual shift has taken place from the 'person approach' to patient safety (in which the individual clinician at the sharp end is blamed for any accident) to a 'systems approach' (in which causation of accidents is attributed to loopholes in the organisational defences). Increasingly, however, concern has been expressed that the systems approach risks absolving individuals from responsibility for patient safety, and a balance between the systems and person approaches has been sought. In this paper, resolution of the tension between the person and the systems approaches is advocated through the use of a paradigm that places more emphasis on the relationships between the individual at the sharp end and other components of the system. This paradigm, which is adapted from ecosystems, has been labelled the 'bionomic approach'. A bionomic approach to patient safety incorporates principles and concepts of human ecology and applies them to the healthcare system, situating the individual as an intrinsic component of the system rather than an adjunct. It builds on the notion that 'people create safety' and on the recognition that, in some clinical areas, particularly surgery, the individual is the primary defence against patient safety incidents. Skills required for 'error wisdom' are described, and the principles of the bionomic approach are applied to gynaecological surgery, using an illustrative case study.