Safety science
Safety science has been shifting focus. For decades, professionals in safety critical industries have focused primarily on reducing risk and minimizing harm by learning everything they can from when things go wrong [1, 2]. Despite tremendous investment in this strategy, the outcomes are disappointing [3]. Safety science continues to evolve and the limitations of a Safety-I only strategy are becoming clearer with growing imperative to expand our thinking and practices [4].
Healthcare is a safety critical industry [5]. The daily work of healthcare professionals contributes directly to life and death outcomes for patients. Healthcare is also a complex adaptive system [2, 6, 7]. Its elements are usually emergent and nonlinear, resulting in unexpected and variable outcomes. It is often difficult, if not impossible, to determine causality with complete certainty [1, 2, 6]. Knowing this, it is challenging to know how best to improve performance and limit harm in when linear models of cause-and-effect rarely apply. Furthermore, it is a challenge to account for the importance of adaptive capacity when defining good performance.
Safety-I…and Safety-II…and Safety-III
A not unfamiliar occurrence to many debriefers is asking an individual or a team to debrief and being met with a response such as “it went great, I don’t think we need to debrief, I wouldn’t have done anything differently.” This is a common example of a historically Safety-I focused mindset around debriefing and a prime opportunity to shift and expand focus. As stated by Sidney Dekker, “Safety is not about the absence of negatives. It is about the presence of capacities.” [8]. Safety-II offers a paradigm that expands on Safety-I to account for the presence of capacities, as well as the complexity and adaptivity of healthcare systems [1, 2, 4, 9]. Safety-II encourages us to study and debrief all events, including the routine and mundane, not only bad outcomes (Fig. 1). By examining everyday work as done, we must confront the reality that written policies and actual practice are often different. Examining work as done also shows the necessity of performance adjustments, variation, and adaptation for successful operations in a complex system. By studying all work and all outcomes, interconnectedness, dependencies, and patterns of systems behavior emerge over many incidents. This information is tremendously powerful and often underutilized in debriefings and in general.
Recently, drawing from her experience primarily in aerospace and defense, Leveson has introduced the concept of “Safety-III”, suggesting a safety management principle that “concentrates on preventing hazards and losses, but does learn from accidents, incidents, and audits of how system is performing.” [10]. We believe that the notion of applying debriefings to both the positive and negative elements of an event is consistent with Leveson’s Safety-III approach.
Safety and role of debriefing
Debriefing after simulated or real clinical events is a powerful tool to capture the knowledge and adaptations of frontline healthcare workers. Routine debriefing also facilitates understanding of system resources and constraints [11]. Debriefing methods have been largely adopted and adapted from aviation and psychology and there are many models of both post-simulation and clinical event debriefing [11,12,13,14,15,16,17,18,19].
Need for debriefing inclusive of Safety-II
Debriefing is a growing practice in healthcare, conducted after planned simulations and high stakes and team events (e.g., cardiac arrest resuscitation, postpartum hemorrhage, trauma care) or unfavorable outcomes and has been demonstrated to improve performance [20] and clinical outcomes [12, 21,22,23]. While debriefing and learning from “positive events” is not uncommon or new to simulation, both simulation and clinical event debriefing programs are often more focused on Safety-I debriefing [20, 23].
Multiple studies support that there is no one correct way to debrief and many advocate for utilizing blended approaches and strategies [11, 24,25,26]. Though several frameworks include analysis of positive performance, there is often limited discussion of the Safety-II concepts such as adaptation, resource utilization, constraints, variability, and work as done [27]. Since the impact of a Safety-I approach is limited, how can clinicians incorporate and bolster Safety-II thinking into the practice of debriefing to improve systems level performance? How can we go beyond learning from failure to debriefing for learning from success [27]? A mindset constricted to Safety-I may not anticipate the value of debriefing when things go well, despite the rich learning potential.
Vignette exploring Safety-II
The following case vignette highlights the value in analyzing when things go right and how to ensure they go right as frequently as possible: An in situ simulation in the pediatric emergency department involving critical care resuscitation with intubation went smoothly with seemingly maximized teamwork and communication, quick equipment retrieval, and first pass success with intubation.
The team leader’s response to request to debrief was “It went great, I don’t think we need to, I wouldn’t have done anything differently.” This reaction was not surprising but rather reflects an anecdotally common perception that debriefings are reserved for “bad outcomes” and “fixing things.” The team appeared genuinely surprised (and fairly apprehensive) of the persistent request to still debrief. Over the next 5 min, a robust discussion unfolded. No one was “sure” why the case went so smoothly. SB posed the question “are there strategies you used in this case or in your normal work with intubation in order to be more efficient or effective?” The resident thanked the nurse for having all of the airway equipment laid out for him and asked the nurse how he has become so efficient with the airway equipment. The resident noted a recent experience in which he struggled to locate a specific endotracheal tube size during a previous pediatric intubation. The nurse, shyly at first, explained that he, and others in this area, finds the airway cart to be very confusing so they actually stock backup endotracheal tubes and blades in a medication room near the resuscitation room. For efficiency, he skipped the airway cart entirely and ran to the medication room to quickly obtain the proper equipment. This reflection uncovered a workaround representing “work as done” that created better performance and could inform reliable performance generalizable to other areas.
The successful workaround was shared with quality leadership and location and layout of the airway carts were changed with this single insight of “work as done” vs. “work as imagined” captured from the nurse during this debriefing. This example of the value of Safety-II and routinely analyzing when things go right highlights how application of Safety-II concepts during debriefing can broaden discussions, capture high yield analysis and improvements that may otherwise not be discussed, and create a broader scope of change applicable to other units who may have similar masked challenges.
Given the paucity of literature and recommendations for how best to debrief for Safety-II concepts (in addition to Safety-I concepts), valuable opportunities for discussion, learning, and systems improvement may be missed. The objective of this pilot was to utilize expert consensus to create a tool for debriefing with a Safety-II focus, including highlighting key Safety-II concepts and provision of sample phraseology.
