Online Safety II Resources
Enhancing Safety Systems: Learning from when things go right
Understanding how real world work occurs allows us to reimagine the design and implementation of governance and systems that can better meet the needs of people (users and receivers) and maximise safe outcomes.
Refinement of system level redesign and reflection locally can then be used to improve both the experience and safety of care.
Principles of Safety II
How can these principles help facilitate changes to how the organisation approaches how safety is measured, planned, investigated and achieved?
Safety II emphasises an understanding of everyday work and the adaptive behaviours that allow complex systems—like healthcare—to function successfully despite variability, uncertainty, and pressure.
This not only offers potential to improve safety systems and outcomes, but can also assist in better understanding how the work of people in the organisation occurs and how barriers that both frustrate them and contribute to risk exist.
Even (especially) in the absence of harm events – learning from normal work
How do we make Decisions in Practice?
The notion of System 1 and System 2 (Dual Process Theory) thinking is not related to safety II specifically but offers insights into how we make decisions in the real world and how those decisions can be framed or influenced. This ultimately can contribute to increased risk and/or increased safety
This approach is not the sole answer to understanding decisions and thinking processes but offers an interesting insight that can be added to the consideration of how we practice in complex environments.
Measuring Safety
Are we Measuring what's important or do we make what we measure important?
Paul McLiesh
'Audits, metrics, and indicators will never truly assess safety. But that's what we keep using. And that’s the problem. We measure safety, but we don’t always understand it'.
Are We Learning from Accidents?
Dr Nippin Anand
Online Resources: Safety II
Application of Safety-II Principles
Provides a simple outline of the principles of Safety II and how they can be used in real world practice Venkatesan et al 2024
It’s time to step it up. Why safety investigations in healthcare should look more to safety science
Presents an argument for healthcare to move beyond existing safety practice’s and engage with contemporary safety sciences- that has largely been unanswered, as yet!
Wiig, S. Braithwaite, J. & Clay-Williams, R.
The problem with making Safety-II work in healthcare
This paper provides a good discussion of the challenges of applying Safety II in healthcare. Aligned with the principles of Safety II- understanding the value of refining practice importantly also requires us to understand the barriers, the risk, the challenges to any refinement so that we recognise how and if those changes should occur Verhagen et al 2022
Strategies and tools to learn from work that goes well within healthcare patient safety
practices: a mixed methods systematic review
A recent systematic review that identifies literature that uses tools and strategies to learn from normal work Birkeli et al 2025
Patient Safety 2.0: Slaying Dragons, Not Just Investigating Them
The purpose of patient safety work is to reduce avoidable patient harm. This requires us to slay dragons—to eliminate or at least mitigate risks to patients. Instead, current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests, and so on. Information about risks is useful to the extent that it informs effective action––but only to that extent. By itself, it does nothing to make patients safer. We cannot investigate a dragon to death. No more can we risk assess our way to safer care. Card 2023
Experience of learning from everyday work in daily safety huddles
Presents a real world example of how the principles of safety II can be applied in the real world Wahl et al 2022
Systems Design & Recognising the Way We Think
Emergency Triage Education Kit
Chapter 4 (Pages 57 - 61) explains how our thinking and decision making can be organised and conducted internally.
It is useful to consider how individuals process information and make decisions, especially when under stress or time pressure.
This has relevance for systems design & governance structures as allowance for adaptability can improve safety, not just risk it. Australian Government: Dept of Health & Aged Care
Do contemporary patient assessment requirements align with expert nursing practice?
This paper discusses contemporary patient assessment requirements and how they articulate with expert nursing practice
McLiesh et al 2023
Cognitive biases in diagnosis and decision making during anaesthesia and intensive care
Discuss the widely accepted dual process theory of cognition and its relevance to bias and diagnosis.
Webster et al 2021
WorkArounds or Desire Paths
The concept of ‘Desire Paths’ has been applied by some researchers to examine, identify and understanding workarounds in clinical practice. Used in urban planning, desire paths are worn sections of a grassed area which have been created over time as people use that route instead of the pre-designed paved pathway. Recognition of this shortcut is a way of identifying the desire of people to walk in that direction rather than use the existing path. This concept has been used in sociology to explore the work of clinicians who use workarounds because their needs are not being met by existing processes, systems and policies (McLiesh et al., 2023; Nichols, 2014; Weeks et al. 2025; Weller et al., 2022).
Systems-based models for investigating patient safety incidents
Workarounds, or adaptions in practice can be a deviation from an intended work practice or policy to overcome an obstacle (real or perceived) to better deliver care. That obstacle may exist because of a poorly designed policy which does not reflect the real-world context or needs, problems with suitable resources (people, equipment or time) or the absence of appropriate guidance for that particular situation. Adaptions occur for a variety of reasons and can result in safe, efficient care or can lead to increased risk and harm occurrence. Acknowledging and examining their existence and how they contribute to risk or safety offers us the ability to better learn from normal work (Work as Done).
Sampson et al 2021
Social Desire Paths: An Applied Sociology of Interests
Recognizing social desire paths in concrete behaviors provides an orienting frame for sociological research to shape policy as well as program creation and improvement at the organizational level.
Nichols et al 2014
Desire paths for workplace assessment in postgraduate anaesthesia training
Research suggests that meeting expectations can be difficult in practice, which has led to the development of informal processes, or ‘shadow systems’ of assessment. Rather than rejecting these informal approaches to workplace assessment, we propose borrowing from sociology the concept of ‘desire paths’ to legitimise and strengthen these well-trodden approaches.
Weller et al 2022
The Desire Path: Integrating Patient Safety and Patient-Centeredness in Health Care Design
Recognition of Desire Paths existing in practice can be used in redesign of work and structures in the healthcare setting.
Weeks et al 2025
Complexity, Solutionism & 'Fixing' Problems
Solutionism is a belief that problems can be solved through technological or scientific innovation, often using a reductionist approach that oversimplifies complex issues and ignores non-technical factors like ethics and human behaviour. While it emphasises a solution-oriented mindset, there are risks which can lead to unintended consequences, dismiss valid non-technical solutions, and over emphasis the value of technical solutions.
Our approach here considers Solutionism a little more broadly and recognises that in healthcare we are often quick to try to ‘fix’ problems before truly ‘understanding’ them.
Problems in healthcare are complex and often require immediate action otherwise people are put at risk. We have become very good at managing these types of problems but it can mean we are not as good at managing more complex problems. Sometimes, the urgent can crowd out the important
Solutionism
To meet the contemporary challenges in healthcare, we need to consider the complexity, explore the influences, understand the 'why' & engage with people at care delivery levels to 'fix' problems. Ensuring that those 'solutions' are not just designed & implemented top down but are grounded in real world needs.
Paul McLiesh LinkedIn Post Aug 2025
Complexity risks creating problems rather than solving them
I've shifted my mindset recently to think about every time we're faced with a problem - what can we take away, rather than add. Each of these questions are critical yet underemphasized in process improvement – What steps can we eliminate? - What decisions can we simplify? - What’s the fastest, clearest path to success? High performance, whether in medicine, business, or leadership, isn’t about complexity. It’s about clarity.Andrew Petrosoniak LinkedIn post 2025
Solutions: Reactive Problem Solving
"In reactive problem solving we walk into the future facing the past — we move away from, rather than toward, something. This often results in unforseen consequences that are more distasteful than the deficiencies removed" - Russell L. Ackoff For a long time, we have told stories for change based on problems. The issue with telling stories for change that focus on problems and pain points is that it results in narrowing our vision down to a problem-solution framing... We then quickly bypass any inquiry into ourselves and the complex systems around us in pursuit of solutions. Solutions come in the form of parts, which are often easily packaged and co-opted by business as usual. Narrowing our vision also often leads to a focus on technical solutions, for which a few understand and control, ultimately leading back to the same concentrations of power. What we really need is to rethink systems and the reorganization of systems, in a way that enables us all to contribute and be part of creating something. Ones that first encourage us to become aware of the limitations of linear thinking, become aware of complex systems, and how we grow and contribute to growing new systems, that work, and work for all.Joss Colchester LinkedIn Post 2025
Getting Rid of Stupid Stuff
The design of systems of work in complex settings like healthcare are full of unintended consequences.
Many of which can increase the risks they are intended to remove or minimise.
Recognising the existence of unintended consequences, the impact they have, the frustration and inefficiencies they create is the start of learning from normal work and identifying Work as Done.
Recognition then allows processes that can look for the inefficiencies and unintended consequences to refine ways of working and system design that makes more sense to people doing the work.
Getting Rid of Stupid Stuff is one of those processes that allows people to report ways of working (work as Intended) that could be reimagned and refined.
Getting Rid of Stupid Stuff
Melinda Ashton describes a system that offers clinicians the ability to identify practice requirements that they find frustrating, that do not contribute to improving safety or quality care.
In complex healthcare systems, governance process or requirements, intended to ensure consistency of care, can instead contribute to risk due to the unintended consequences that are poorly recognised or measured. GROSS is a way of identifying those unintended consequences and considering revising those requirements to reduce the burden for staff
Process or ways of removing activities that do not contribute to safe and effective care, can help to ensure that practices that directly contribute to safe outcomes are prioritised.Ashton 2018
In complex healthcare systems, governance process or requirements, intended to ensure consistency of care, can instead contribute to risk due to the unintended consequences that are poorly recognised or measured. GROSS is a way of identifying those unintended consequences and considering revising those requirements to reduce the burden for staff
Process or ways of removing activities that do not contribute to safe and effective care, can help to ensure that practices that directly contribute to safe outcomes are prioritised.Ashton 2018
A Safety-II Perspective on Organisational Learning in Healthcare Organisations- Hassle Reporting
This process of “hassle reporting” is very simple, and can be empowering when healthcare workers are encouraged and supported by senior management to develop solutions within their own work environment. The focus on hassle and on how people deal with it avoids potentially threatening notions of human error and patient harm, and should thus reduce fear of repercussions.
Sujan 2018