What is safety II?
Safety II recognises that in everyday work, people adapt to the constraints they face. Manty of those challenges in practice are not able to be addressed by existing polices or procedures.
This is a form of resilience where the ability to adapt, anticipate and monitor are essential actions in keeping people safe in complex systems of work. Those adaptions can result in both safe and unsafe care, so the same decisions made by different people, at different times can have both successful and unsuccessful outcomes in different scenarios & times.
A safety framework that creates opportunities to learn from normal work and identifies the existence, motivation and implications of those adaptions can expand our safety learning
Embrace Human Adaptability as a Resource Staff flexibility and problem-solving are essential to safety. People are seen as contributors to safety, not just sources of error.
Supports Staff: Recognising staff as resources enhances trust, morale, and engagement.
Builds Resilient Systems: Healthcare is dynamic and unpredictable; Safety-II helps systems adapt and sustain safe performance even under stress. Enhances Patient Care: By focusing on successful outcomes and adaptive capacity, patient safety can improve beyond
compliance-driven models.
How a Nurses Story can justify & Guide System Redesign
This is the story of Petra (not a real person!) who is a nurse.
This is the story of how her practice has evolved over time and how she experiences contemporary nursing requirements in her daily practice. This video is intended to provide context for how complexity in healthcare has created a range of unintended consequences. Providing a justification for re-imagining health systems design.
CONTEMPORARY SAFETY PRACTICE & SYSTEMS
Contemporary safety practices in healthcare remain primarily linear in their design and approach, and consider incidents and adverse events occurring as a result of a chain of events with identifiable or root causes
(Ball & Frerk, 2015; Wiig et al., 2020).
This approach is generally reactive, failure orientated and retrospectively focussed, with the purpose of investigating why and how something negative occurred.
LEARNING FROM WHEN THINGS GO WRONG
This creates a potentially misleading assumption that an absence of adverse events or accidents is indicative of safe care delivery and that the systems, policies and requirements, without the presence of an incident, are working effectively to keep people free from harm (Nazaruk, 2023; Wahl et al., 2022).
From this perspective, the definition of safe practice then becomes – a system where as few things go wrong as possible
(Scanlon & Jacobson, 2025).
SAFETY II FRAMEWORK
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This framework provides a visual depiction of the principles of Safety II
Pillars:
Each pillar represents an element of practice and system design. Each incorporates Safety I elements which are built on by further safety learning using a Safety II framework.
This demonstrates that Safety II is not intended to replace existing practices but strengthen and complement it.
Rows:
The two rows represent each of the foci of Safety Learning.
'Work As Intended' is how work is imagined and believed to occur in daily practice- shaped by policies & procedures etc.
Our Safety Learning has traditionally been measured using this approach. Usually considering compliance of practice against guided practice (policy etc). Any variation then becomes a focus to 'fix'.
'Work As Done' recognises work as imagined but also considers how work actually occurs in practice and how that work can contribute to and/or risk safety.
Attempts to move 'Work As Done' closer to 'Work As Intended' is a common focus of contemporary healthcare systems- intended to ensure consistency and limit variations.
While well intended, this risks failure to recognise the adaptions that occur daily that contribute to safe outcomes but are not part of 'Work As Intended'
Those adaptions offers us insights into the unintended consequences of our governance systems, the work requirements that are an inefficient use of workers time/a source of frustration and proactive insights into where risk lies lurking!
Copyright McLiesh 2025
Work as Done - Work as Intended
Work As Intended
This is how our work is directed by policies & procedures.
This is the systems view of how work occurs and what people do daily. There is an assumption that if people practice in ways that are guided by policies and procedures, then safe practice will be achieved.
The view that either things are functioning as intended and required or they are not and that increases risk
Work As Done
This describes what happens in real world practice in response to complex systems and scenarios and ever-changing conditions.
There is a recognition that Work as Intended and Work as Done are going to differ. This can be the source of both Safety AND Risk
Work as Done will often go beyond the policies and procedures, and in most situations is what keeps people safe.
Work As Measured & Documented
This aligns with Work as Done.
Not all Work as Done is Documented and therefore may not be measured
We should consider what measures we use to determine safety and quality of practice.
Safe practice may occur but be poorly documented and measured.
Care that occurs but not documented is a very different problem to care that does not occur (where it should).