Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies

[Note. This is a repost of an older post but now in article format]

This studied procedural departures in community pharmacies, using Safety-I and Safety-II to help frame and discuss the findings. 24 participants (pharmacists and support staff) were interviewed using the critical incident technique.

S-I was framed mostly as the absence of incidents and taking a generally negative view of procedural departures, whereas S-II was framed as people attempting to manage system complexity.

I couldn’t always follow the internal logic of how they framed the findings (nor necessarily always agreed with the frames or what constituted a S-I or S-II perspective or example…some seemed arbitrary).

In any case, I haven’t focused much on the specific S-I/S-II frames in my summary – but the full paper is worth a read if you’re interested.

Results

31 procedural departures were described in the interviews – for multiple reasons. 14 were classified as routine, 4 as optimising, 8 as situational and 5 as exceptional.

For S-I view, procedural digression could be seen to pose a risk to patient safety. However, participants worked in a conflicted environment where they were urged to work efficiently while maintaining patient care. They found this tension challenging, where efficiency was felt to be favoured in many cases, and procedures departed to manage this tension.

The tension was found to place staff in a state where departures were seen as both right (where management supported efficiency) and wrong (possibly placing patients at risk).

Staff noted specific circumstances justified procedure departure, but were concerned that others would judge the situation as inappropriate without knowing the contextual factors. On reflection, some staff said they would not again choose to depart from procedures in a less pressured situation; highlighting the criticality of understanding contextual factors in performance.

One staff member said that the pressures to depart were largely based on contextual factors and that it wouldn’t be necessary if workload could be managed. Including some procedures being seen to be unnecessarily detailed and inefficient.

Noted was that pharmacies need flexibility to manage safety, particularly in urgent situations. But, not surprisingly, “procedures in [pharmacies] do not always account for contextual factors” (p117) or permit this flexibility.

Staff were conscious that some efficiency gains in procedure departures could potentially increase risk, but on the balance, typically felt the departures were low risk compared to the benefits.

From the S-II view, many departures were seen by staff as ones unlikely to result in adverse outcomes and helped to maintain routine pharmacy performance. This was seen as examples of the difference between work-as-imagined vs work-as-done.

Social norms within pharmacies impacted on departures – where routine departures appeared to “ease relationships in the workplace” (p117). Here, staff said it was easier to continue acting in the same manner as others rather than insisting on following procedures.

Some staff felt uneasy about departing from procedures – especially when asked by general practice staff. However, *not* departing also had consequences. Thus, staff had to manage the tension between meeting the situation but also professional relationships.

Authors suggest that using a broader approach (S-II and S-I) may allow better understanding of context, and therefore, permit more beneficial social norms to be fostered.

Overall, many departures were found to be a response by staff to manage their complex environment; adjustments made to respond to real conditions, where procedures provide little support, and where staff use professional judgement to balance tensions.

However, as per other research – the constant need for staff to adapt can give the impression of a well-functioning system, while masking system inefficiencies and emerging risks. Further, although staff saw departures as necessary to maintain both safety and efficiency, some examples were found where only productivity was maintained.

Nevertheless, it’s noted that judging departures as right or wrong is problematic, especially without context and in the critical light of hindsight (as most departures resulted in successful performance).

Further noted is that, in healthcare, departures may be better understood as a form of situated action rather than rule breaking. As an example, anaesthetists in other research were found to act based on what they interpret as appropriate action in each situation, even though they’re provided with best practice guidelines.

Finally, as one way forward, the authors suggest that companies could try to better integrate S-I/S-II tensions by introducing flexible procedures or guidelines, that provide better support and decision aids for staff; rather than a single way of ‘doing’.

That is, some procedures could better address variability, rather than just assume it doesn’t exist or try to eliminate it.

Link in comments.

Authors: Jones, C. E., Phipps, D. L., & Ashcroft, D. M. (2018).?Safety science,?105, 114-120.