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Using Safety-II and resilient healthcare principles to learn from Never Events
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Using Safety-II and resilient healthcare principles to learn from Never Events
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Journal Article
Using Safety-II and resilient healthcare principles to learn from Never Events
2020
Overview
Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events.
Qualitative and quantitative retrospective analysis of RCA reports.
A large acute healthcare Trust in London.
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Quality of RCA reports, robustness of actions proposed.
RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events.
Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.
