When Things Go Right: Safety II in an Academic Emergency Department

Objectives Historically, "safety" has been defined as an absence of error. Practice variability of any kind has been viewed as a threat. This is termed Safety I. Meanwhile, Safety II posits that clinician practice variability is a necessary adaptation required to meet patient needs in a complex healthcare system. We hypothesize that clinicians in the emergency department (ED) make proactive adaptations and utilize practice variability to enhance safety. Methods This is a cross-sectional survey-based study of clinical team members at a tertiary care academic ED with an annual census of 76,000. Qualitative data on instances of proactive safety were collected and analyzed via inductive response analysis. Ratings of support for practice adjustments and experiences of negative emotions during practice variability were collected using 5-point Likert scales. Results There were 84 respondents, of which 33 (39%) were nurses, 28 (33%) were physicians, and 23 (27%) held other clinical roles. Qualitative data included 128 instances of harm prevention, with some respondents describing more than one. Instances include proactive safety via collaboration (n = 47; 36.72%), time-based interventions (n = 46; 35.94%), physical harm prevention (n = 27; 21.10%), and patient/visitor interactions (n = 8; 6.25%). Of respondents, 73.17% (n = 30) felt that policies matched daily work most of the time, and 92.68% (n = 38) felt enabled to adapt to the needs of a patient most of the time. Experiences of self-doubt, fear of repercussion, or anxiety occurred most when adhering to a policy despite patient needs (n = 20; 48.78%). Conclusions Clinical team members report keeping patients safe through various forms of behavior adaptations, most frequently reporting collaboration beyond usual expected practice. Respondents report policies to match daily work most of the time and feel enabled to adapt to the needs of patients. Feelings of self-doubt, fear of repercussion, or anxiety were reported most frequently when clinicians adhered to a policy despite the needs of a patient.