We are looking for a safety scientist or human factors professional with experience of healthcare to undertake three months’ work with us. The aim of the project is to use Safety II/Resilience Engineering theories and frameworks to analyse a series of 39 Never Events. Traditional safety practices view adverse events as occurring when there are departures from protocols. Solutions therefore often involve training and protocol development, especially for nurses. However, these solutions are often ineffective, as indicated by the continuing occurrence of Never Events.
Resilience theory proposes that the complexity of the healthcare environment is the key to understanding how adverse events occur. Clinicians create safety by adapting to pressures and challenges, and adverse events happen when adaptive capacity is eroded. Understanding how to prevent never events, from this perspective, involves understanding the work system and its complexity.
We want to investigate what this Safety II perspective might add to our understanding of Never Events and how to prevent them. The work will involve desk based analysis of a series of Never Event reports to produce a framework for incorporating Safety II perspectives into Never Event analysis. We will gain stakeholder input into the framework and produce guidance for applying it.
The ideal person to undertake this work is someone with knowledge of safety problems in healthcare and understanding of theories of human error, accident causation and/or Safety II and Resilience Engineering. The work must take place over a three month period from May to July, 2018. All approvals and materials are in place for the project to start in May. Work can be carried out remotely if necessary, but some face to face meetings in London will be necessary. For further information, please contact:
Dr. Janet Anderson
Director, Centre for Applied Resilience in Healthcare
King’s College London