1. Safety-I, Safety-II, And the Messy Details of Clinical Work Robert L Wears, MD, MS, PhD University of Florida Imperial College London International System Safety Society 8 October 2015

2. apologia and cautions background in healthcare almost exclusively the ER trying to overcome my background as a doctor … 2

3. 2 important differences organic vs engineered systems 3

4. 2 important differences irreducible ambiguity 4

5. motivation general agreement that we are not making progress on safety as fast as we would like what’s typically being said … we have not been ‘Protestant enough’ more rigour (eg, EBM) greater accountability ‘just do it harder’ 5

6. motivation general agreement that we are not making progress on safety as fast as we would like what’s not being said wrong mental model of safety – utopian scientism “… enduring Enlightenment projects “… rationality can create a better, more controllable world “… taken for granted by safety researchers b/ it appears so ordinary, self-evident and commonsensical.”* 6 *Dekker 2012

7. patient safety orthodoxy technocratic, instrumental, ‘measure- and-manage’ approach myopic – failing to question underlying nature of problems overly simplistic – transferring sol’ns from other sectors negligent of knock-on effects of change ‘amateur social science’ “glosses over the complexities of health care organisation and delivery” 7

8. a missed opportunity clinical expertise necessary but not sufficient for safety “‘errors’ in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine” - J Senders, 1994 needed to partner with ‘safety sciences’ psychology, human factors engineering, social science, communication, etc but instead got ‘scientific-bureaucratic medicine’ managerial rationalism wearing the mantle of science ‘the safety Nazis’ ‘we have ways of making you safe…’ 8

9. safety is a ‘wicked problem’ 9 “… it is far harder to make progress on safety than we thought … the programmatic approaches (checklists, team training, reporting) are all quite positive about the effects of their interventions but the experience we have when trying to apply those approaches is uniformly unsatisfying. “… the factors that create ‘the safety problem’ are deeply embedded in the system of work [including all the incentives and organizational structures that surround and promote work] and these programs don’t alter these factors. The system we have is a product of numerous compromises and sacrifices that are needed to “make things work” and the deep system that results is far more anchored and grounded than we appreciate. “… Instead, we have chosen to do things that give the appearance of improving safety so that we can feel better … these programs make it easier for us all to live with deeply flawed, dangerous systems.

10. safety is a ‘wicked problem’ 10 “This explains why we have so many programs for safety: we embrace a program to make ourselves feel better about the system of work. This does make us feel better, for a while. But eventually the deep system demonstrates in clear, unambiguous fashion, that we haven’t made real progress. Instead of taking this as evidence that we have fundamentally misunderstood what is going on, we conclude that we chose the wrong program and look for another one to restore our sense that we are making progress on safety. “To be sure there are real advances. Our technology, knowledge, and skill are constantly improving. But we choose to exploit these advances to accomplish more or to spend less rather than to make the work itself safer. We struggle to do this in a ’safety neutral’ way — ie, trying to keep the bad outcomes at about the same level as before while benefitting from the improvements — but this is always a process of discovery because the forms of failure are constantly changing.” - R I Cook, 2014

11. limits of the Enlightenment “good ideas that are nevertheless incorrect” - René Amalberti 11

12. simple models of accidents are delusions 12

13. simple models of accidents are delusions 13

14. complex adaptive systems distinguish between simple, complicated, and complex problems baking a cake landing on the moon raising a child little expertise required, highly standardized, formulaic solutions work many causes, many parts, break into simple problems & manage piece by piece complexity emerges from interaction of parts, can’t be decomposed, must deal with the whole 14

15. complex adaptive systems distinguish between simple, complicated, and complex problems taking vital signs placing a central line handing off a pt or unit little expertise required, highly standardized, formulaic solutions work many causes, many parts, break into simple problems & manage piece by piece complexity emerges from interaction of parts, can’t be decomposed, must deal with the whole 15

16. complex adaptive systems separating complicated and complex is essential placing a central line handing off a pt or unit particulars, context largely irrelevant paradigmatic mode of thinking particulars, situatedness, context are everything narrative mode of thinking 16

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19. modern theories of accidents simple, linear, chain of events complicated, interdependent complex, nonlinear, coupling, resonance, emergence evolution of system safety 19 1940 1960 1980 2000

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21. view from safety-I accidents come from erratic acts by people (variability, mistakes, errors, violations) study, count accidents to understand safety (tend to look backwards) focus on components safety is acquired by constraining workers via: standardisation, guidelines, procedures, rules, interlocks, checklists, barriers 21

22. assumptions in safety-I our systems are well-designed and well-understood procedures correct and complete systems are basically safe, well-protected reliability = predictable, invariant variation is the enemy safety is an attribute (something a system has) conditions are well-anticipated, well-specified 22

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24. view from safety-II accidents are prevented by people adapting to conditions study normal work to understand safety (tends to look forward) focus on inter-relations aim is to manage, not eliminate, the unexpected safety is enacted by enabling workers via: making hazards, constraints, goal conflicts visible enhancing repertoire of responses 24

25. assumptions in safety-II our designs are incomplete, procedures out-dated our systems are poorly understood systems are basically unsafe reliability = responsiveness variation is necessary safety is an activity (something a system does) possible failure modes have not been anticipated ‘continuing expectation of surprise’ 25

26. safety-II 26 complex STS intractable, underspecified, variable demands resources (time, people, material, information) limited, uncertain workers adjust to meet conditions creating variability adjustments always approximate (b/ resources limited) approximate adjustments usually reach goals, make things go safely approximate adjustments sometimes fail, or make things go wrong “Knowledge and error flow from the same mental source; only success can tell one from another.” Ernst Mach, 1905

27. safety-I vs safety-II summary defined by its opposite - failure well designed & maintained, procedures correct & complete people (ought to) behave as expected & trained accidents come from variability in above therefore safety comes from limiting & constraining operators via standardization, procedures, rules, interlocks, barriers critical inquiry ‘work as imagined’ defined by its goal - success poorly understood, incomplete, underspecified people (ought to) adjust behaviour & interpret procedures accidents come from incomplete adaptation therefore safety comes from supporting operators via making boundaries, hazards, goal conflicts visible, enhancing repertoire of responses appreciative inquiry ‘work as done’

28. philosophical bases safety-I linear, proportional, tractable behaviour explained by reduction positivist, Taylorist cause-effect simple, oneway controllable ‘the one best way’ work as imagined values declarative, technical knowledge complicated problems techne, episteme safety-II non-linear, non-proportional, intractable behaviour explained by emergence constructivist, interpretivist cause-effect multiple, reciprocal influence-able equifinality, multifinality work as done values practice, tacit wisdom complex, ‘wicked problems’ mētis, phronesis 28

29. empirical support direct observations & NSQIP data surgeons w/ best results had just as many untoward events as those w/ worst but they had better means of detection greater repertoire of responses de Leval 2000 Ghaferi 2009 29

30. another important difference resilient vs brittle systems 30

31. resilience – multiple conceptions first appeared ~1600s from Latin resiliens “to rebound, recoil” re- “back” + salire “to jump, leap” rebound from some traumatic event 31

32. resilience – multiple concepts robustness expand base capacity to handle more disruptions ‘enlarging design basis’ brittleness vs graceful degradation bring ‘extra’ adaptive capacity to bear in the face of potential for surprise 32

33. contrasting examples directions GPS (to bullets) CDs, mp3s most digital maps LPs most analog 33

34. resilience – formal definition the ability of systems to adapt to sustain key operations in the face of expected or unexpected challenges 34

35. resilience and success not just success in the fact of threats (resilient systems still fail) repertoire of behaviours, shifting performance, trading off goals to dynamically forestall failure, mitigate failure in progress, or seize opportunities “… redirect the failure pathway to another form from which recovery might be easier, less disruptive, less costly” Cook, RI 2014 35

36. but a problem resilience only seen through its instantiations like static electricity – can’t see it, but can see lightning 36

37. epiphenomena “… seeing holes or deficiencies in hindsight is not an explanation of the generation or continued existence and rationalization of those deficiencies.” Dekker, S. W. A. (2011). Drift into Failure: From Hunting Broken Components to Understanding Complex Systems. Farnham, UK: Ashgate. 37

38. problem for engineering resilience “… seeing heroic recoveries in hindsight is not an explanation of the generation or continued existence and rationalization of those recoveries.” à la Dekker, S. W. A. (2011). Drift into Failure: From Hunting Broken Components to Understanding Complex Systems. Farnham, UK: Ashgate 38

39. hidden resilience resilience must be present before it is manifested “much of the stock of [a system’s] response is in the form of latent behavioural potential … outside of awareness and taken for granted until interruptions and attempts at recovery call attention to it” Christianson, M. K., Farkas, M. T., Sutcliffe, K. M., & Weick, K. E. (2009). Learning through rare events: significant interruptions at the Baltimore & Ohio Railroad Museum. Organization Science, 20(5), 846 - 860. 39

40. WAI vs WAD the messy details paramedics told to handoff to ED charge nurse get back out on street faster charge nurse won’t be taking care of pt not as interested in details will hand off to another nurse ‘secret, second handoff’ 40

41. WAI vs WAD the messy details diagnostic workup for cancer should be ‘fire & forget’ 2/3 of cases required 1 or more additional staff actions no difference in time to dx 41

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44. risks in human activities no system beyond this point 10 -2 10 -3 10 -4 10 -5 10 -6 civil aviation nuclear industry railways chartered flight chemical industry (total) fatal risk blood transfusion elective surgery very unsafeultra safeunsafesafe mountaineering professional fishing off shore drilling oil industry (total) anesthesiology asa 1-2 radiotherapy emergency icu oncology medical risk (total) fire fighting satellite launch space missions rotary wing trams, tubes

45. no system beyond this point 10 -2 10 -3 10 -4 10 -5 10 -6 civil aviation nuclear industry railways chartered flight drilling industry chemical industry (total) fatal risk anesthesiology asa1 innovative medicine (transplant, oncology …) icu, trauma, ed very unsafeultra safe professional fishing three contrasting safety models unsafesafe mountaineering combat c/c, war time ultra resilient context: taking risks is the essence of the work cult of fighter spirit, champions, heroes, villains safety model: power to experts ‘give me best chances and safest tools to survive in these adverse conditions and make exploits’ safety training: learning through shadowing, acquiring professional experience, "training for zebra", working on knowing one's own limitations unknowable events model ultra safe context: risk is excluded as much as possible cult of applying procedures and safety rules by an effective supervisory organization safety model: power to the regulators of the system to avoid exposing front-line actors to unnecessary risks training in teamwork to apply procedures and manage work even if abnormal events occur precluded events model medical risk (total) radiotherapy blood transfusion elective surgery chronic care reliabilty model context: risk is not sought out, but it is inherent in the activity cult of group intelligence and adaptation to changing situations safety model: power to the group, ability of the group to organize itself (roles), to provide mutual protection to its members, to apply procedures, to react to anomalies, to adapt, perceive changes and make sense of changes in the context training in teamwork to gain knowledge of abilities and adaptability in applying procedures to suit the context react to events model finance fire fighting food industry processing industry more safety-I more safety-II

46. conclusions – maybe? health care has many resilient systems the sources of that resilience are not clear resilience is being consumed to enhance productivity this is normal (fr Richard Cook) 46

47. resources http://resilienthealthcare.net/ 2016 workshop and call for papers White Paper on Patient Safety Turning Patient Safety on its Head http://www.resilience-engineering-association.org/ Plans for 7 th REA Symposium will appear here Fairbanks et al (2014). Resilience and resilience engineering in healthcare. Joint Commission Journal on Quality and Patient Safety, 40(8), 376 - 383. Woods, D. (2015). Four Concepts for resilience and the Implications for the Future of Resilience Engineering. Reliability Engineering & System Safety, 141, 5-9. 47

48. contact information Robert L Wears, MD, MS, PhD wears@ufl.edu r.wears@imperial.ac.uk +1 904 244 4405 48