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Translating Safety II Theory into Practice


Two health care professional looking a computer monitor.

By Jenna Merandi, PharmD, MS, CPPS; Stacy Kuehn, RN, BSN; Tensing Maa, MD; and Richard Brilli, MD, FAAP, MCCM

The Safety II approach to improving patient safety acknowledges that things go right far more often than they go wrong. 

Because of this, various learning opportunities exist regarding how individuals and systems make things go right. Organizations can enhance their safety efforts by focusing less on Safety I or “what went wrong,” and instead focus greater attention on Safety II or “what can be learned from the numerous successful outcomes.” 

As we looked around our organization at Nationwide Children’s, we found multiple microsystems had intuitively applied Safety II strategies to their safety work, resulting in improved outcomes. These interventions, detailed in this study from the August 2021 issue of The Joint Commission Journal on Quality and Patient Safety, had evolved separately, over time, across clinical units and we sought to coordinate them at the macrosystem level. 

Terminology – Does the Name Matter?
Key Safety II concepts include:

  • resilience engineering
  • learning from excellence
  • positive deviance
  • adaptive capacity

As we shared Safety II principles across our organization, we often encountered confusion related to:

  • terminology
  • the tendency of labeling Safety I vs. Safety II 
  • staff implicitly assigning value distinctions (Safety II better than Safety I) rather than seeing them as complementary

To make Safety II concepts easily recognizable, understandable and actionable, we shifted our terminology from Safety II to “proactive safety.” This resonated well with our staff and opened the door for more innovation. Our strategy for making Safety II concepts more practical for the bedside clinician was to focus on intervention design under three main elements:

  1. recognize (monitor and anticipate)
  2. respond
  3. learn 

Proactive Safety Framework 
Developing a framework to operationalize Safety II theory has been challenging for many hospitals across the country. There is a need to better understand how successful frontline health care workers adapt their everyday work and develop systems to support proactive safety efforts.

Nationwide Children’s designed a proactive safety framework which has served as the compass for enhancing our safety program and includes the following elements:   

  • Safety tools – Three tools were designed to influence and enhance proactive safety behaviors:
        1. Pause to Predict: enhances real-time situation awareness and encourages frontline staff to intentionally gather information, understand the context of information and anticipate potential outcomes.  
       2.  IDEA:  stands for Investigate all the facts, Discuss with two or more team members if acting outside of standard process/protocol, Explore all options and Accept questions from everyone regardless of role or hierarchy. 
       3.  Feed Forward: reminds individuals to communicate lessons learned and help others be successful in providing patient care.  
  • Proactive safety huddles – Brings an interdisciplinary team of stakeholders together to proactively plan and anticipate potential problems from unusual patient situations that may require unique actions. Team members develop ways to mitigate risk before an error occurs. 
  • Proactive safety plan documentation – A communication order in the electronic health record visibly displays the patient’s proactive plan and provides situational awareness for any inpatient care teams. 
  • Proactive safety observations – Safety experts perform workflow observations, evaluate how work is done, and proactively identify and address system weaknesses before an error occurs.
  • Simulation – In-situ simulations are performed with interprofessional care teams to test systems and enhance process improvement. Latent safety threats are identified and mitigated prior to reaching an actual patient. Frontline safety concerns are communicated to leadership.
  • Appreciative inquiry – Represents a paradigm shift from traditional “what went wrong” investigations to learning from “what went well.” Utilizing successful cases to investigate, identify strengths and behaviors that led to positive patient outcomes promotes learning and a strong safety culture. 
  • Human factors engineering – Designing systems to make it easier to do the right thing and harder to do the wrong thing is essential in proactively mitigating risk at the system level. Considerations of how humans interact with the system, technology, environment and their tasks should all be a part of the equation in moving toward system-level design of enhanced safety behaviors.

Future Directions
Nationwide Children’s continues to work with other pediatric hospitals across the country and collaborate with various other high-risk industries like aviation to move Safety II/proactive safety concepts from theory into practice. As Peter Drucker quoted, “the task of leadership is to create an alignment of strengths so strong that it makes a system’s weaknesses irrelevant.” 

Jenna Merandi, PharmD, MS, CPPS, is Medication Safety Officer in the Pharmacy Department at Nationwide Children’s Hospital in Columbus, Ohio. Stacy Kuehn, RN, BSN, is Manager of Nurse Educator Informatics at Nationwide Children’s Hospital. Tensing Maa, MD, is Director of Simulation in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Nationwide Children’s Hospital. Richard Brilli, MD, FAAP, MCCM, is the John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality and Safety at Nationwide Children’s Hospital. Dr. Brilli also is Professor Emeritus, Pediatrics and Pediatric Critical Care Medicine, at Ohio State University College of Medicine in Columbus, Ohio.