@article{13372,
  author = {Janet E. Anderson and Alison J Watt},
  title = {Using Safety-II and resilient healthcare principles to learn from Never Events},
  abstract = {<jats:title>Abstract</jats:title>
               <jats:sec>
                  <jats:title>Objectives</jats:title>
                  <jats:p>Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Design</jats:title>
                  <jats:p>Qualitative and quantitative retrospective analysis of RCA reports.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Setting</jats:title>
                  <jats:p>A large acute healthcare Trust in London.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Participants</jats:title>
                  <jats:p>None.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Interventions</jats:title>
                  <jats:p>None.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Main outcome measure</jats:title>
                  <jats:p>Quality of RCA reports, robustness of actions proposed.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Results</jats:title>
                  <jats:p>RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events.</jats:p>
               </jats:sec>
               <jats:sec>
                  <jats:title>Conclusion</jats:title>
                  <jats:p>Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.</jats:p>
               </jats:sec>},
  year = {2020},
  journal = {Int J Qual Health Care},
  volume = {32},
  pages = {196-203},
  month = {02/2020},
  issn = {1353-4505},
  doi = {10.1093/intqhc/mzaa009},
}