Rethinking learning from incidents in healthcare: a Safety-II model integrating work-as-imagined, work-as-done, and...

Area of Science:

• Healthcare systems analysis
• Patient safety research
• Complex adaptive systems

Background:

• Healthcare organizations increasingly use systems thinking for patient safety incidents.
• Current incident reviews often revert to linear, event-focused reasoning, recommending retraining rather than addressing systemic issues.
• A key unresolved question is whether identified 'deviations' are exceptional behaviors or typical system operations.

Purpose of the Study:

• To propose a Safety-II model for incident review to enhance system learning.
• To differentiate between exceptional behavior and the system's typical mode of operation during incident analysis.
• To provide a framework for understanding everyday adaptations in complex adaptive healthcare systems.

Main Methods:

• Proposing a Safety-II model with three analytical lenses: work-as-imagined, work-as-done, and work-as-experienced.
• Introducing a prevalence-indexed analysis of work-as-done using longitudinal electronic medical record and operational data.
• Establishing whether flagged practices represent exceptions or norms within the system.

Main Results:

• The proposed model aims to shift focus from individual non-compliance to systemic adaptations.
• Prevalence-indexed analysis can differentiate between typical system operations and exceptional deviations.
• Transparency regarding the gap between documented and enacted work is crucial.

Conclusions:

• A Safety-II model offers a more robust approach to patient safety incident review.
• Distinguishing between typical operations and exceptions is vital for effective system learning.
• This framework supports better understanding of complex adaptive healthcare systems and informs proposals for regulators and organizations.