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Implementing Tools to Enhance Safety II at a Children’s Hospital


By K. Suresh Gautham, MD, DM, MS, FAAP 

 After the seminal Institute of Medicine (IOM) report launched the patient safety movement in 1999, a variety of safety approaches from other industries such as aviation, nuclear power generation, operation of aircraft carriers and transportation were adapted for use in health care. This phenomenon was termed ‘translocation’ (as opposed to translation) by patient safety expert Robert Wachter, MD.   

 Today, we are all familiar with a number of such concepts, methods and tools, including: 

  • Swiss cheese model 
  • root cause analysis 
  •  failure mode and effects analysis 
  • use of checklists 
  • structured communication formats such as SBAR
  • technology-based automation  

As concepts of patient safety evolve and as we continue to learn from other industries, there has been a growing realization that such methods are only partially effective and may not promote deep-rooted and sustainable promotion of patient safety because they: 

  • impose linear, overly simplified concepts on systems that are complex and dynamic 
  • are reactive, with their use being triggered after the occurrence of a safety event
  • focus on errors, not safety  

Safety II 
This has led to interest in applying the concepts of resilience engineering in health care and in promoting an approach of Safety II (proactive safety), which focuses on maintaining safety by using human adaptation skills, improvisation and variability. Safety II encourages the use of concepts such as ‘work as done’ in place of ‘work as imagined’ and encourages human responsiveness to changing needs and circumstances.  

 Four key competencies for workers are proposed in Safety II:  

  • monitor 
  • anticipate 
  • respond
  • learn 

While the concepts and principles of Safety II are appealing and easy to understand at an abstract level, there is a paucity of actual tools and techniques that allow health care organizations to implement Safety II.  

In the upcoming July 2021 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), Bartman and colleagues report how they designed and implemented actual tools and methods within their organization to encourage health professionals to practice Safety II in their daily work. 

The study authors describe tools such as: 

  • Pause to Predict  
  • IDEA (an acronym for Investigate, Discuss, Explore and Accept)
  • Feed Forward 

They also outline how they educated staff about these tools and provide a clinical vignette to illustrate how these tools can be applied.  

To learn more about the study, please visit the JQPS website.  

 K. Suresh Gautham, MD, DM, MS, FAAP, is Deputy Editor for The Joint Commission Journal on Quality and Patient Safety, Senior Editor of the Neonatal Review Group of the Cochrane Collaboration and Professor of Pediatrics at Baylor College of Medicine, Houston.