Acknowledgements

A great many people contributed to make the workshop possible and successful. We would like to express our deepest appreciation and thanks to:

• Martin Hatlie, the Executive Director of the National Patient Safety Foundation (NPSF) at the AMA for his encouragement and tireless work to create the National Health Care Safety Council as a part of the Foundation and to initiate this workshop as its first activity.
• The United States Department of Veterans Affairs (VA) and the Agency for Health Care Policy & Research (AHCPR) for sponsoring and participating in the workshop, for their leadership on patient safety, and for their willingness to listen to the results from other fields in the search for progress on safety in health care.
• The many participants in the workshop who gave of their time, energy, and intellect to wrestle with the difficult questions that underlie safety in the complex and changing world of health care.
• The Board of the American Medical Association for providing the facilities to hold the workshop.
• The staff of the National Patient Safety Foundation who provided critical assistance over long hours to set up, run and document the workshop so smoothly.

Many people helped to prepare this report as a means to share the ideas and interchanges at the meeting with others. In particular, we would like to recognize the contributions of Carter Mecher, MD, Larry Goldman, MD and Jeffrey Cooper, PhD who provided valuable comments to help the shape the content of the report.

A special thanks is due to Lorri Zipperer, Information Project Manager of the NPSF who led the production and editorial process. She, along with George Kruto who indexed the material, Rosalyn Robinson of the AMA who coordinated the printing, and Karen Dangremond, of Dangremond Design, Chicago, Il. who created the layout and design of the text, handled the myriad aspects required to produce this document. Thanks Lorri for coordinating everyone and applying the right mixture of tact and forcefulness to make this report come to fruition.

Richard I. Cook      David D. Woods

Prelude

Exploring contrasts is a powerful means for achieving new insight. Dickens juxtaposes contrasting individual stories to tell the much larger story of the French Revolution and the Terror. The first line of the novel points out that the contrasts are striking, provocative, paradoxical, and compelling. Far from resolving the contrasts in favor of one position or the other, the novel shows how this period contained all of these qualities.

For health care at the end of the twentieth century, it is also the best of times and the worst of times, a time of paradoxes and contrasts. On the one hand, splendid new knowledge, more finely honed skills, and technical advances bring sophisticated treatments to larger and more fragile populations of people than ever before. On the other hand, media and public attention is focused on "celebrated" medical accidents-chemotherapy overdoses, wrong limb surgeries, catastrophic missed diagnoses. Stunning success and appalling failure are arrayed in contrast to each other. It is in this setting that discussions about patient safety are now taking place.

Because the sources of safety and the threats to safety remain poorly understood and because scientific research on health care safety is in its infancy, the National Patient Safety Foundation at the AMA, with sponsorship from the Department of Veterans Affairs and the Agency for Health Care Policy Research, convened a workshop in December 1997 to assemble results from the science on human performance and safety from past research in other areas.

The workshop was structured around the stark contrasts between two kinds of stories we tell about accidents. Some accidents become highly visible, widely known, "celebrated" cases, e.g., the Florida 'wrong leg' case. In the first story we tell about such cases, we are puzzled. Given what we now know after-the-fact, they seem so easily preventable and the human performance so poor. We can see how the outcome could have been avoided if the people involved had just recognized the significance of some data or if they had been more careful in carrying out an activity. We fall back on explanations such as "human error" and stop, wondering how we can cope with the unreliability of the human element.

Results from close, methodical, scientific investigation of specific areas of practice in health care where failures occur (e.g., the vulnerabilities that contribute to patient injury during minimally invasive gall bladder surgery) tell a different, deeper and more complicated story. The detailed investigations are second stories revealing the multiple subtle vulnerabilities of the larger system which contribute to failures, detecting the adaptations human practitioners develop to try to cope with or guard against these vulnerabilities, and capturing the ways in which success and failure are closely related.

The second stories examine how changes in technology, procedures, and organizations, combine with economic pressures to create new vulnerabilities and forms of failure at the same time that they create new forms of economic and therapeutic success. The result is paradoxical: health care becomes simultaneously more successful and more vulnerable (or vulnerable in new ways). The changes that create opportunities and vulnerabilities also encourage human adaptation to exploit opportunity and defend against vulnerability. Individuals, teams and organizations adapt their practices and tools to guard against known threats to safety. But complexity limits the success of these adaptations. Hazards are hidden, tradeoffs difficult to assess, and the coupling across seemingly distant parts is obscured.

Digging for second stories is valuable because it promotes learning about systemic vulnerabilities. The efforts of individuals, teams and organizations to make safety are limited. People and organizations may miss or misperceive the vulnerabilities and how they come together to create paths toward failure; they may rely too much on human adaptability; they may develop brittle strategies, or they may rely on past success when change creates new challenges. How well people and organizations make safety depends on feedback to recognize systemic vulnerabilities, to evaluate the robustness of their adaptations and to understand how the changing context of medical practice affects vulnerabilities. Recognizing systemic vulnerabilities guides investments to cope with these contributors toward failure. Promoting this flow of information to learn about systemic vulnerabilities is one of the hallmarks of a safety culture.

In the workshop and in this report, the contrast between celebrated medical failures and well researched areas of human performance in medicine is used to expose the difference between the First Story of "human error" and the Second Story of systemic vulnerabilities. The different stories reveal another contrast about progress-only by constantly seeking out our vulnerabilities can we develop and test more robust practices to enhance safety.