What if we accepted that humans are necessary for system flexibility rather than a problem to be fixed?
Did you know that by some estimates, an RN performs a workaround of a process 94% of the time, or that when we try to determine the “root cause” of errors and near misses, we are only examining less than 3% of all the processes occurring around the error? Moreover, most policy subscribes to the assumptions that safety systems are well designed and maintained; procedures are comprehensive and correct; policy designers have seen every contingency; and people are expected to behave exactly as expected—a concept first developed at the start of the 20th Century.
As we move further into the 21st Century, rather than examining only what went wrong, we could take a better look at why things work. This is the concept behind “mundane simulation,” where instead of focusing solely on an event where things went wrong, we examine the regular, but non-trivial actions that lead to successful outcomes. The continued expansion of multiple layers of technology over the last thirty to forty years has made most of the environments where we work in healthcare infinitely more complex. Often, this complexity overwhelms well-meaning policy, and healthcare staff adapts to accomplish their tasks, regardless of prescribed practice. This is where workarounds begin. Unfortunately, this separation from prearranged process and workaround in a complex environment makes it difficult to separate normal variation in performance from both a pathway toward excellence as well as risk. This normal variation in performance creates a “corridor of accepted normal performance”. Above this “corridor” exists recognizable good quality performance, while below the corridor, there exists poor quality performance.
Simulation of the mundane allows the investigator to measure the normal variation inherent to successful systems operations. Through a thorough understanding of this normal variation, educators can recognize performance that are approaching the lower boundary of the corridor and make corrections prior to a failure rather than investigating root cause following an event.
This movement away from a critique of the poor performance to an in-depth investigation of successful outcomes is a paradigm shift away from how we have typically thought of simulation. For educators developing scenarios and debriefing skills to investigate current practice will require additional training and practice. For learners, the idea of simulating something normal will require an explanation for the change. For administrator, the necessity of creating highly realistic environments that include actual staff rather than stand-ins could be expensive; however, the benefits of working within the system’s dynamics rather than trying to implement policy to address all eventualities may provide a pathway to fewer errors.
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Dieckmann, P., Patterson, M., Lahlou, S., Mesman, J., Nyström, P., & Krage, R. (2017). Variation and adaptation: learning from success in patient safety-oriented simulation training. Advances in Simulation, 2(1), 21.
Hollnagel, E., Wears, R. L., & Braithwaite, J. (2015). From Safety-I to Safety-II: a white paper. The resilient health care net: published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.