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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Health matters—Theory to practice

What happens when a Safety-II approach is taken to the work of a multidisciplinary team working in intensive care? CARL HORSLEY reports from the front line.

I work as an intensive care specialist in the Critical Care Complex (CCC) at Middlemore Hospital, Counties Manukau Health. I’m part of a multidisciplinary team that cares for the sickest patients in the hospital, including those with life-threatening infections, major burns, spinal cord injuries and trauma; from small babies right through to the very old or very large. Our workload is unpredictable, and each patient needs highly individualised, time-critical care.

In areas of healthcare like Emergency Medicine and Intensive Care, Safety-I approaches are often a poor fit for daily work. Rules introduced to make work “safer” may be unfollowable in these dynamic conditions, and inadvertently create new complexity and risk. Frontline healthcare workers see in Safety-II a better representation of their work and the way staff create safety as they navigate the uncertainty and competing demands of everyday work.

Additionally, Safety-II values people and teams as the key resource to navigate the complexity of our work. With the increasing rates of staff burnout and disengagement seen in healthcare, this valuing of people and the work they do is an important contributor to staff wellbeing. It stands at odds with previous approaches which had little curiosity about the realities of everyday work.

While there has been much discussion about Safety-II, it can be hard to know where to start in applying the ideas in a practical way. Over the last few years, we have found three principles that have been transformative for our work: make usual success more likely; learn from all events; and build resilient teams and systems.


Safety-II reframes safety as a state where “as much as possible goes right”. For us, this meant thinking about how to make usual success more likely by ensuring our team had what they needed to provide good care.

However, to do this successfully meant leaving behind our preconceived ideas of how our teams worked (Work-as-Imagined) and instead being curious about the realities of daily work in the clinical area, the Work-as-Done. This shift from compliance to curiosity has led to sustained improvements in areas we had previously struggled with, such as hand hygiene.


A common misperception of Safety-II is that it is only about looking at what goes well. In reality, it is about understanding all outcomes, seeing both how usual success is created, and understanding why what normally works sometimes doesn’t.

One of the key changes for us has been to create space for the team to reflect on normal work. Previously, we had only taken time to debrief events that had a poor outcome. Successful team performance was just “as it should be”. This meant that the work done by the team to create success, often in difficult situations, was invisible and unvalued, and problems that were successfully overcome remained hidden.

Now, regardless of the outcome of a major event, we routinely ask our teams:

  • • 
    What happened the way you thought it would?
  • • 
    What surprised you?
  • • 
    What hazards did we identify and what hazards did we miss?
  • • 
    Where did we have to “make do”, improvise or adapt?

This reflective approach also occurs when we have a case with an unwanted outcome.

Our reviews have moved from “What was so different about this case?” to instead “What does this case tell us about normal work?”

It has meant exploring why the actions of those involved made sense to them at the time, as others facing the same situation in future could make those same choices. It has shifted our focus away from blaming individuals to instead being curious and engaging with them to learn deeper lessons about our system.


Resilience in this setting refers to “the ability of the team or system to adjust performance to achieve its goals, even when the unexpected happens”. It is about enhancing the ability of our teams to adapt and respond to threats and opportunities as they arise.

In the CCC, this led to significant changes in the way we trained our teams through simulated cases. The focus was on bringing the diverse experience and viewpoints of our teams together and building the necessary psychological safety to enable everyone to contribute actively. This focus on building adaptable teams has had perhaps the greatest impact, with improved team performance, a more anticipatory focus and greater engagement from staff leading to better care for our patients.


Safety-II is a shift to seeing safety as something to be actively created, where performance and safety are aligned by “as much as possible going right” and where people are at the heart of how we design our systems and navigate changing conditions.

To make it work, you need to leave behind judgement and instead take the time to be curious about the realities of work. You need to pay attention to the way success happens and understand that people are your key resource needed for the uncertain, changeable future we all face.


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