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Learning from things going right...
Resilience Strategies: Developing Support for Analysis

Key points

  • Most of the time things go right. Understanding why can be as important as understanding why things do go wrong, but is often ignored. By better understanding and sharing the way people adapt what they do to avoid making mistakes we can help make healthcare safer.
  • We have developed a new concept: 'resilience strategies' to refer to the informal and inventive actions people take to avoid making mistakes and/or to improve performance.
  • We have identified different types of resilience strategy, creating a categorisation scheme for them.
  • We have also developed frameworks for analysing and understanding these strategies including how and why they work.
  • We are now using this knowledge to help understand how patients and healthcare practitioners self-manage. This will lead to improvements in the design and use of medical devices.

Background
To err is human… is a well known phrase and the title of an influential report on patient safety. Much is written about how things go wrong. Far less is written on how things go right. In part, this is because when things go right nothing remarkable happens. However, it is a mistake to think that there is nothing to learn in the absence of things going wrong.

Humans try to avoid erring too! Humans try to manage errors they know they might make along with managing other risks. We are aware of our own fallibility and similarly, the reliability of others. We write down dates and times in our diary because we know we would probably forget them, we set timers on our oven so we are reminded when the food is ready, and we double-check the times, date and year of a holiday booking before paying for it. Other everyday resilient behaviours include labelling similar cables and chargers to make it easier to tell them apart, sticking our own instructions on a microwave or photocopier, or jotting a note on the back of our hand when there isn't a notepad within reach.

Strategies to avoid making mistakes
We have carried out studies, combining different approaches and with different communities, to explore how people avoid making mistakes in different settings. Similar approaches occur in both everyday and professional settings - including the medical context. To make the study of these activities more tangible we have introduced a new notion of resilience strategies. We have then developed new ways to recognise, describe and make sense of them.

We have classified the different types of things people do to avoid mistakes: things that cannot be foreseen by official procedures alone. For example, one category is 'creating new cues or artefacts'. This includes composing notes and instructions, and setting timers as described above. Another category is 'separating and disambiguating items' which includes the above example of labelling similar cables to avoid mixing them up. 'Pre-commitment checks' includes the holiday booking example. We are currently taking steps to show how and why these strategies work, and based on this, we are developing guidance on how to design devices that support clinicians and help them reduce overall risk to patients.

One challenge in understanding how resilience strategies are used in practice is that people rarely talk about them and under-report their use when asked about them. When an error occurs in a medical setting, it may result in a patient being harmed and so be recognised and reported. When a nurse uses a resilience strategy to prevent an error, this is seldom discussed never mind published. This potential way to improve patient safety is therefore often overlooked. These informal strategies for avoiding error and improving performance can be valuable to others who might use them. They also provide a way for management to bridge the gap between work as imagined (i.e. how they think staff work) and work as done (i.e. how staff actually cope with work, including the shortcuts and workarounds they employ).

To overcome this, we have initiated discussion across a range of audiences including academics, patients and the wider public, promoting the value of considering what goes right in everyday interactions, not just what goes wrong. For example, we delivered a public lecture on the Comedy of (Human) Error and Cognitive Resilience to about 20 researchers and members of the public. We also organised an international workshop for about 20 researchers and practitioners from different domains on resilience strategies at the Resilience Engineering Symposium in 2013. Some of this work has been recognised and used by other researchers, including in a keynote by Erik Hollnagel, and as shown through the many references to our Resilience Markers Framework which assists with the identification and analysis of resilience strategies. Additionally, as part of work towards developing this framework, we have identified and developed a range of ways to collect and record strategies, across a variety of settings (both within and outside of healthcare). One novel way is through our Errordiary project (errordiary.org). It collects resilience strategies from members of the public and we have used it to engage with people with diabetes, medical professionals and the public.

The study of human performance isn't just about how people makes errors or mistakes, we are moving towards the study of the positive aspects of human performance, and in so doing, are learning from the various tactics and strategies that people use across all manner of tasks and settings everyday. Applying this idea to healthcare, we aim to help patients and practitioners to help themselves in terms of maintaining performance and coping with threats and challenges.

See Also…
Errordiary: achievements and contributions

Key People
Dom Furniss, Jonathan Back, George Buchanan, Ann Blandford & Jonathan Day

Publications
Furniss, D., Back, J., Blandford, A., Hildebrandt, M., & Broberg, H. (2011). A resilience markers framework for small teams. Reliability Engineering and System Safety, 96(1), 2–10.

Furniss, D., Back, J. & Blandford, A. (2011). Unwritten Rules for Safety and Performance in an Oncology Day Care Unit: Testing the Resilience Markers Framework. Proc. Fourth Resilience Engineering Symposium.

Furniss, D., Back, J., & Blandford, A. (2012). Cognitive resilience: Can we use Twitter to make strategies more tangible? Proceedings of European Conference on Cognitive Ergonomics (ECCE 2012), 96–99. New York: ACM.

Furniss, D., Barber, N., Lyons. I., Eliasson, L., & Blandford, A. (2013). Unintentional nonadherence: Can a spoonful of resilience help the medicine go down? BMJ Quality & Safety, in press.

Day, J., Furniss, D., & Buchanan, G. (2015). Meals and Ingredients: Coping with Compound Resilience Strategies. Proc. 6th Symposium of the Resilience Engineering Association, Lisbon, Portugal, June 2015.

Buchanan, G., Back, J., Furniss, D., & Blandford, A. (2011). Attention: Can appropriation be linked to an individual's resilience? Paper presented at the workshop on Appropriation and Creative Use at CHI 2011, Vancouver, BC, Canada, May 2011.