A novel approach to explore Safety-I and Safety-II perspectives in in situ simulations-the structured what if functional resonance analysis methodology

Abstract

Objectives: With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES.

Methods: The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected by human variability, to explore human adaptations observed in in situ simulations (ISS). The structured applicability of this novel approach to TES is described by application to empirical data from the standardised ISS management of paediatric time critical head injuries (TCHI).

Results: A case series is presented to illustrate the step-wise observation of key timings during ISSs, the construction of FRAM models and the visualisation of the propagation of human adaptations through the FRAM models. The key functions/actions that ensure the propagation are visible, as are the sequelae of the adaptations.

Conclusions: The approach as described in this paper is a first step to illuminating how to explore, analyse and observe the consequences of positive and negative human adaptations within simulated complex systems. This provides TES with a structured methodology to visualise and reflect upon both Safety-I and Safety-II perspectives to enhance patient safety and patient outcomes.

Keywords: Emergency medicine; Paediatrics; Patient safety; Simulation; Training; Trauma.

Fig. 1

An example of a FRAM function

Fig. 2

The development of SWI-FRAM models from in-situ simulations

Fig. 3

A FRAM model depicting the interacting functions involved in constructing a FRAM model. This is a relatively simple FRAM model where all functions can be easily checked in an external peer review process, then by the FMI software

Fig. 4

The FRAM model of WAI

Fig. 5

TTL adaptation of declaration of time-critical head injury to the team

Fig. 6

TTL adaptation of assessing the neurological status of the child then declaring head injury to the team

Fig. 7

TTL adaptation of leading a brief team huddle then declaring findings and actions required to the team.

Fig. 8

TTL adaptation of continual reassessment to determine injury pattern

Fig. 9

The SWI-FRAM analysis of the case three (ISS 12). In this figure, the SWI-FRAM analysis is shown cycling through the system (see online video supplementary file 6 also), as the disability / neurological assessment (checking pupils and GCS) is completed, the analysis will continue through to the huddle, then the declaration and on-going care plans