All entries for November 2017

November 26, 2017

Kellogg et al on the problems with the learning created from root cause analysis

Follow-up to New (Safety–II) directions for organisational learning in healthcare from Mark's blog on safety research and teaching

I read Kathryn Kellogg and colleagues' paper on Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

In the paper the authors describe their findings of the analysis of solutions generated from RCAs at one hospital over an 8-year period. They argue that the most common solutions proposed by the RCA teams are also the most ineffective ones - training, policy reinformcement and disciplining. They provide nice examples (awful in terms of the learning generated) from the RCA reports about how investigation teams are stuck in a work-as-imagined frame of mind believing that their protocols are working effectively, but human errors undermine them.

It is precisely this failure to critically reflect on their assumptions that hinders much progress in patient safety (no double-loop learning). Investigators of safety incidents should study work-as-done, trying to understand the mismatches between protocols and actual practice.

Then, of course, the next step is to abandon the belief that learning needs to focus on what went wrong, and start appreciating the learning that could be harnessed by looking at how people make things work on a daily basis - Safety-II in action.


KELLOGG, K. M., HETTINGER, Z., SHAH, M., WEARS, R. L., SELLERS, C. R., SQUIRES, M. & FAIRBANKS, R. J. 2017. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Quality & Safety, 26, 381-387.

November 23, 2017

New (Safety–II) directions for organisational learning in healthcare

I am currently writing a commentary for International Journal of Health Policy & Management on Russel Mannion and Jeffrey Braithwaite's editorial "False Dawns and New Horizons in Patient Safety Research and Practice" (1). Russel and Jeffrey provide an insightful critique of traditional patient safety improvement efforts, and provide a powerful alternative vision based on Safety-II thinking.

In my commentary I apply the Safety-II perspective to organisational learning in healthcare organisations. My key argument is that healthcare organisations have been struggling to learn from experience, because they are concerned only with incidents and adverse events - the extraordinary catastrophe (2). What these approaches fail to appreciate is the role of performance variability and the manifold adaptations by healthcare workers who prevent daily disruptions and tension from turning into daily disasters (3). In my opinion organisational learning should be concerned just as much with the ordinary everday clincal work (work-as-done) as with the extraordinary failures (4,5). A corollary that follows from this is that organisational learning should be democratic and encompas frontline communities of practice, rather than being the remit of a central risk management facility (6).


[1] Mannion, R. and Braithwaite, J., 2017. False dawns and new horizons in patient safety research and practice. International Journal of Health Policy and Management.

[2] Sujan, M.A., Pozzi, S. and Valbonesi, C., 2016. Reporting and learning: from extraordinary to ordinary. Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done, p.103.

[3] Sujan, M., Spurgeon, P. and Cooke, M., 2015. The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emergency care. Reliability Engineering & System Safety, 141, pp.54-62.

[4] Sujan, M.A., Huang, H. and Braithwaite, J., 2016. Learning from incidents in health care: Critique from a Safety-II perspective. Safety Science, 99, pp115-121.

[5] Sujan, M. and Furniss, D., 2015. Organisational reporting and learning systems: Innovating inside and outside of the box. Clinical Risk, 21(1), pp.7-12.

[6] Sujan, M., 2015. An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. Reliability Engineering & System Safety, 144, pp.45-52.

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