Offering the latest news in health care quality and safety, the ISQua blog also features guest posts from the best and brightest in the industry.

By Jeffrey Braithwaite, ISQua Board Member Friday. Apr 12, 2019

Safety-II – the changed paradigm of patient safety Featured

In recent years momentum has been building around a relatively new idea in patient safety which has come to be called Safety-II. Previously, to produce safe care for patients, the majority of activities involved looking at when things go wrong and attempting to reduce harm.


This spawned many initiatives and programs including systematically reporting incidents, hand-hygiene campaigns, using check-lists to ensure procedures are carried out faithfully and conducting root cause analyses whenever major adverse events occurred. All this activity was meant to stamp out harm or reduce adverse events to as low a rate as possible.


However, whenever large-scale studies were conducted to measure how much harm was produced by modern health systems, it became clear that the rate of harm has flatlined for 25 years at around 1:10 patients. Safety-II, on the other hand, asks a superficially simple but in fact quite profound question: how come so much care goes right? This idea is predicated on the point that despite the complexity of modern healthcare, 9:10 episodes of care have no harm associated with them.


So, it becomes a legitimate question to ask: how can we produce more good care, as well as how do we reduce poor care? The two approaches, Safety-I and Safety-II, working together, may do a better job than under the old system, where the preoccupation was with harm reduction and minimising the occurrence of adverse events.


A group of researchers, policymakers and clinicians have published widely in this new paradigm in the Resilient Health Care series, a multi-volume set of books articulating how Safety-II works. Here are some key references for those wishing to read more widely.




Braithwaite, J., Churruca, K., Ellis, L.A., Long, J., Clay-Williams, R., Damen, N., Herkes, J., Pomare, C., and Ludlow, K. (2017) Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments: A White Paper. Australian Institute of Health Innovation, Macquarie University: Sydney, Australia. ISBN: 978-1-74138-456-7.

Braithwaite, J., Hollnagel, E., Hunte, G.S. (eds) (forthcoming) Resilient Health Care Volume 5: Working Across Boundaries. Boca Raton, FL, Routledge: Taylor & Francis Group.

Braithwaite, J., Wears, R.L. and Hollnagel, E. (2015) Resilient health care: turning patient safety on its head. International Journal for Quality in Health Care, 27(5): 418-420. doi: 10.1093/intqhc/mzv063.

Braithwaite, J., Wears, R.L. and Hollnagel, E. (eds) (2017) Resilient Health Care Volume 3: Reconciling Work-as-Imagined and Work-as-Done. Abingdon, UK, Taylor & Francis. ISBN: 978-1-4987-8056-8.

Hollnagel, E., Braithwaite, J., Wears, R.L. (eds) (2013) Resilient Health Care, Farnham, Surrey, Ashgate Publishing Ltd. ISBN: 978-1-4094-6978-0.

Hollnagel, E., Braithwaite, J., Wears, RL. (eds) (2018) Resilient Health Care Volume 4: Delivering Resilient Health Care. Abingdon, UK, Routledge: Taylor & Francis Group. ISBN: 978-113-860-225-0.



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