Safety-I vs Safety-II
Safety-I (Traditional Approach)
- Focus: Things that go wrong (accidents, errors)
- Humans: Seen as a liability / source of error
- Goal: Prevent failures through barriers and rules
- Methods: Root cause analysis, find-and-fix
Safety-II (Resilient Approach)
- Focus: Things that go right every day
- Humans: Resource for flexibility and adaptation
- Goal: Ensure success under varying conditions
- Methods: Understand performance variability and resilience
“Safety is the ability to succeed under varying conditions.” — Hollnagel, Wears & Braithwaite (2015)
The Four Resilience Abilities
| Ability | Definition | Paramedic Example |
|---|---|---|
| Anticipate | What might happen next? | Anticipating deterioration during transport |
| Monitor | What is happening now? | Continuous ETCO₂ and SpO₂ monitoring |
| Respond | What should we do right now? | Switching to BVM + PEEP when monitor fails |
| Learn | What can we take forward? | Sharing adaptations in Coffee & Cases debrief |
Real-World Paramedic Scenarios
Scenario: Difficult Airway in the Field
Monitor fails mid-intubation. Crew adapts using manual checks and backup plan. Outcome: First-pass success achieved.
Safety-II lens: How anticipation, monitoring and response turned potential failure into success.
Scenario: Multi-Casualty MVA
Resource overload. Team re-prioritises using triage adaptations learned from previous incidents.
Safety-II lens: Learning from what went right last time enabled safe care today.
Safety-II Strategies for Paramedicine
Practical Strategies
- Use daily clinical debriefs (Coffee & Cases) to capture what went right
- Build resilience margins (extra oxygen, backup comms, flexible protocols)
- Model high-risk procedures with FRAM to visualise variability
- Celebrate adaptations in team handover and education sessions
Personal & Team Reflection
- Think of your last difficult job: What adaptations did the crew make?
- How often do we celebrate “what went right” in shift handover?
- What small change could your team make this week to increase adaptability?
Functional Resonance Analysis Method (FRAM)
The 6 Aspects of Every Function
| Aspect | Description |
|---|---|
| Input | What starts the function? |
| Output | What does it produce? |
| Time | Timing constraints? |
| Control | Rules, procedures, guidelines |
| Preconditions | Must be true first |
| Resources | What is consumed? |
Paramedic Example: RSI Function
Variability: Monitor fails (resource variability) → crew adapts using manual checks (resonance = successful outcome).