Browse > Article
http://dx.doi.org/10.14371/QIH.2021.27.1.2

What Will We Learn from the Paradigm Shift in Safety Science for Improving Patient Safety?  

Lee, Sang-Il (Department of Preventive Medicine, College of Medicine, University of Ulsan)
Publication Information
Quality Improvement in Health Care / v.27, no.1, 2021 , pp. 2-9 More about this Journal
Abstract
Patient safety remains one of the most important health care issues in Korea. To improve patient safety, we have introduced concepts from the field of safety science such as the Swiss cheese model, and adopted several methodologies previously used in other industries, including incident reporting systems, root cause analysis, and failure mode and effects analysis. This approach has enabled substantial progress in patient safety to be made through undertaking patient safety improvement activities in hospitals that are systems-based, rather than individual-based. However, these methods have the shared limitation of focusing on negative consequences of patient safety. Therefore, the paradigm shift from Safety I to Safety-II in safety science becomes the focus of our discussion. We believe that Safety-II will complement, rather than replace, Safety-I in the discipline of patient safety. In order to continuously advance patient safety practices in Korea, it is necessary that Korea keeps abreast of the recent global trends and development in safety science. In addition, more focus should be placed on testing the feasibility of new patient safety approaches in real-world situations.
Keywords
Accident prevention; Patient safety; Safety management; Risk management;
Citations & Related Records
연도 인용수 순위
  • Reference
1 Hollnagel E. Safety-I and Safety-II: the past and future of safety management. London, Unithed Kingdom: CRC Press; 2014.
2 Yang JY. Brief review of resilience engineering. Occupational Safety & Health Issue Report 2019;13(1):14-23.
3 Rasmussen J. Risk management in a dynamic society: a modelling problem. Safety Science. 1997;27(2):183-213.   DOI
4 Leveson N. A new accident model for engineering safer systems. Safety Science. 2003;42(4):237-70.   DOI
5 Filho APG, Jun GT, Waterson P. Four studies, two methods, one accident - an examination of the reliability and validity of accimap and STAMP for accident analysis. Safety Science. 2019;113: 310-7.   DOI
6 Wachter R, Gupta K. Understanding Patient Safety, 3rd Edition. New York, United States of America: McGraw-Hill; 2018.
7 Underwood P, Waterson P. A critical review of the STAMP, FRAM and accimap systemic accident analysis models. In Stanton NA(ed). Advances in Human Aspects of Road and Rail Transportation. Boca Raton, Untied States of America: CRC Press, 2012.
8 Kohn KT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, D.C., United States of America: National Academies Press; 1999.
9 Haskins J. 20 years of patient safety [Internet]. Washington, D.C., United States of America: Association of American Medical Colleges; 2019 [cited 2021 March 18]. Available from: https://www.aamc.org/news-insights/20-years-patient-safety
10 Wears R, Sutcliffe K. Still Not Safe: Patient safety and the middle-managing of American medicine. New York, Untied States of America: Oxford University Press; 2019.
11 Aven T. What is safety science? Safety Science. 2014;67:15-20.   DOI
12 Bates DW, Singh H. Two decades Since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs. 2018;37(11):1736-43.   DOI
13 Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A, et al. Is health care getting safer? British Medical Journal. 2008;337(7680):1205-7.
14 Vincent C, Amalberti R. Safer Healthcare: Strategies for the Real World. [Internet]. [cited 2021 March 29]. Available from: https://link.springer.com/book/10.1007%2F978-3-319-25559-0
15 Righi AW, Saurin TA, Wachs P. A systematic literature review of resilience engineering: Research areas and a research agenda proposal. Reliability Engineering & System Safety. 2015;141:142-52.   DOI
16 Borys D, Else B, Leggett S. The fifth age of safety: the adaptive age. Journal of Health Services Research & Policy. 2009;1(1):19-27.
17 Hollnagel E, Paries J, Woods D, Wreathall J. Resilience engineering in practice: a guidebook. Farnham, Unithed Kingdom: Ashgate Pub Co; 2011.
18 Hollnagel E. FRAM : the functional resonance analysis method. Farnham, Unithed Kingdom: Ashgate Pub Co; 2012.
19 Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: A White Paper. [Internet]. [cited 2021 March 29]. Available from: https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf
20 ISQua J. Safety-II - the changed paradigm of patient safety. [Internet]. [cited 2021 March 29]. Available from: https://isqua.org/news/safety-iithe-changed-paradigm-of-patient-safety
21 McNab D, Bowie P, Morrison J, Ross A. Understanding patient safety performance and educational needs using the 'safety-II' approach for complex systems. Education for Primary Care. 2016;27(6):443-50.   DOI
22 Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Services Research. 2012;12:150.   DOI
23 Catchpole K, Russ S. The problem with checklists. BMJ Quality & Safety. 2015;24(9):545-54.   DOI
24 Macrae C. The problem with incident reporting. BMJ Quality & Safety. 2016;25(2):71-5.   DOI
25 Mannion R, Braithwaite J. False dawns and new horizons in patient safety research and practice. International Journal of Health Policy and Management. 2017;6(12):685-9.   DOI
26 Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Quality & Safety. 2017;26:417-22.   DOI
27 Carson-Stevens A, Donaldson L, Sheikh A. The rise of patient safety-II: should we give up hope on safety-I and extracting value from patient safety incidents? comment on "false dawns and new horizons in patient safety research and practice". International Journal of Health Policy and Management. 2018;7(7):667-70.   DOI