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IntroductionThe Resilience Analysis Grid (RAG) is a Safety-II instrument to evaluate a systems potential for resilient performance based on the four resilience potentials Responding, Monitoring, Learning and Anticipating. Since its development, only a few studies worldwide tried to bring the RAG theory into healthcare practice. In the Netherlands, the Safety-II approach has become central to patient safety in hospitals. However, there are still few instruments available to support reflection on the resilient performance of hospital systems. Given that hospital work is predominantly team-based, hospital teams and their wards provide a valuable starting point for fostering reflection on resilience in healthcare settings. This study aims to identify key factors that facilitate the use of the Resilience Analysis Grid for evaluating resilient performance in hospitals while also introducing Safety-II principles into hospital wards.MethodWe applied action research methodologies to iteratively experiment with the RAG. In collaboration with healthcare professionals from the SAZ, an association of general hospitals, and Medirisk, a Dutch mutual insurance company, we explored how to apply RAG theory in practice. The study consisted of three phases. Phases 1 and 3 included online workshops with participation from all SAZ-associated hospitals. In Phase 2, we conducted RAG reflection workshops at the emergency wards of five SAZ hospitals, involving medical, nursing, and management staff. Throughout each phase, we observed the workshops and interviewed participants about their experiences with the RAG to identify key elements for its effective use.ResultsWe identified several key elements that support the use of the RAG in hospital wards, ultimately leading to the development of the Safety-II reflection cards. These elements include the presence of a multidisciplinary group of healthcare professionals in the RAG reflection workshop, a facilitator with expertise in Safety-II principles, and a collaborative selection of a complex procedure for reflection. Additionally, fostering a shared language, cultivating an open culture, ensuring a willingness to dedicate time and space, and recognizing resilient performance as an ongoing work-in-progress are essential for effective implementation.ConclusionsRAG theory, implemented through the Safety-II reflection cards, offers specific reflection principles that make the Safety-II perspective more practical for healthcare professionals when assessing their work procedures. These principles are particularly useful for complex processes in settings like emergency rooms and intensive care units, where they help strengthen patient safety.

Seoul virus (SEOV) is a zoonotic orthohantavirus carried by black and brown rats, and can cause hemorrhagic fever with renal syndrome in humans. Human cases of SEOV virus infection have most recently been reported in the USA, United Kingdom, France and the Netherlands and were primarily associated with contact with pet rats and feeder rats. Infection of rats results in an asymptomatic but persistent infection. Little is known about the cell tropism of SEOV in its reservoir and most available data is based on experimental infection studies in which rats were inoculated via a route which does not recapitulate virus transmission in nature. Here we report the histopathological analysis of SEOV cell tropism in key target organs following natural infection of a cohort of feeder rats, comprising 19 adults and 11 juveniles. All adult rats in this study were positive for SEOV specific antibodies and viral RNA in their tissues. One juvenile rat was seropositive, but negative in the rRT-PCR. Of the 19 adult rats of which subsequently additional organs were tested, SEOV RNA was detected in all lungs, followed by kidney (79%) and liver (74%). Histopathologic changes associated with SEOV infection were primarily found in the liver, consistent with a pathological diagnosis of a mild hepatitis. In conclusion, natural SEOV infection results in mild inflammation of the liver in the absence of clinical disease.