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Using Safety-II and resilient healthcare principles to learn from Never Events

Research output: Contribution to journalArticlepeer-review

Janet E. Anderson, Alison J. Watt

Original languagePortuguese
Pages (from-to)196-203
Number of pages8
JournalInternational journal for quality in health care : journal of the International Society for Quality in Health Care
Issue number3
Published20 May 2020

King's Authors


Objectives: 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. Design: Qualitative and quantitative retrospective analysis of RCA reports. Setting: A large acute healthcare Trust in London. Participants: None. Interventions: None. Main outcome measure: Quality of RCA reports, robustness of actions proposed. Results: 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. Conclusion: 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.

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