Safer Healthcare

I've just finished reading Safer Healthcare. For me, the main take-home message is the different kinds of safety that pertain to different situations. Vincent and Amalberti describe three different approaches to safety:

• ultra-safe, avoiding risk, amenable to standardised practices and checklists. This applies to the areas of healthcare where it is possible to define (and follow) standardised procedures.
• high-reliability, managing risks, which I understand as corresponding to "resilient" or "safety II" – empowering people within the system to learn and adapt. This seems to apply to a lot of healthcare, where the variabilities can't be eliminated, but can be managed.
• ultra-adaptive, embracing risk. This relies on the skills and resilience of individuals. This applies to innovative techniques (the very first heart transplant, for example) where it really isn't possible to plan fully ahead of time because so much is unknown and it relies on the skills of the individual.

The authors draw on the example of rock climbing. The safest forms of climbing (with a top-rope, which really does minimise the chances of hitting the ground from a fall) are in the first category; most climbing falls into the second: we manage risk by carefully following best practice while accepting that there are inherent risks; people more adventurous than me (and more skilled) push the boundaries of what is possible – both for themselves and for the community. But it is also possible to compromise safety, as graphically described by James McHaffie addressing Eve Lancashire whose attitude to safety worries him (see about half way through the post).

Vincent and Amalbeti's categorisation highlights why comparing healthcare with aviation in terms of safety is of limited value: commercial aviation is, in their terms, ultra-safe, with standardised procedures and a lot of barriers to risk; healthcare involves far too much variability to all be amenable to such an approach.

Another point Vincent and Amalberti make is that incidents / harm very often don't happen within one episode of care, but evolve over time. I am reminded of a similar point made in a very different context by Brown and Duguid, who described the way that photocopier engineers learn about their work (and the variability across machines and situations): the describe it as being like the "passage of the sun across the sky" – i.e., it's not really clear when it starts or end, or even exactly how it develops moment to moment. So many activities – and incidents – don't have a clear start and end. Possibly the main thing that distinguishes a reportable incident is that there is a point at which someone realises that something has gone wrong...