Safety Science Overview
When failure occurs in any agency, the common response is to use reactionary approaches such as firing employees, writing new policies, or retraining staff. These approaches have poor results when it comes to making systems safer. In fact, they may have an opposite effect. Using reactionary approaches, evidence suggests agencies may be less safe because true accounts of how the system operates and how it can be improved are kept underground. Employees are less likely to account for how things may go wrong and are less likely share how these issues can be avoided in the future because of fear they may be sanctioned or even fired. This may leave agencies with the false impression that they have dealt with a problem, when in fact it may have become worse. Furthermore, these reactionary approaches are detrimental to staff.
Agencies must evolve from outdated models of safety commonly used today. Current models of safety engage employees in safety related efforts, establish comprehensive approaches to analyzing adverse events and promptly act upon identified areas of improvement. These models have been championed by safety critical industries such as aviation, healthcare and nuclear power. The industries that use these updated models of safety depart from surface level understandings of how systems fail and seek out the complex interplay of systemic factors. When typical underlying systemic factors are addressed, an agency can begin to make critical advancements in promoting safe outcomes for their employees and the people and customers they serve.
In order to promote the shift to a systemic and proactive culture of safety, agencies need to be supported to make three key transitions:
From a culture of blame to a culture of accountability,
From continuously applying quick fixes to addressing underlying systemic issues, and
From seeing employees as a problem to control to a solution to harness.
The Three Transitions
Towards a culture of accountability
The terms blame, and accountability are too often conflated. When agencies blame and punish workers, they falsely believe that the agency and its employees are being accountable for their actions. Years of research have shown that blame may decrease accountability, since it inhibits the ability of the organization to learn and improve. Accountability engages frontline workers to be a part of the solution by providing their experience of how adverse events may have occurred and how they can be avoided in the future. Additionally, the agency is accountable to make improvements and to focus efforts and resources on becoming a more resilient and reliable organization.
Towards addressing underlying systemic issues
In the wake of failure, it is tempting for agencies to use quick fixes such as firing employees, adding new policy or retraining staff. This leaves agencies with the false impression that a problem has been resolved. However, agencies are still left with the systemic constraints and influences that contributed to an adverse event. This is commonly seen as treating symptoms instead of the source of the illness. Instead, agencies need to track and address the underlying systemic factors that are present in many adverse events and are likely to be present in the future.
Towards seeing people as the solution
Common approaches to improvement whether following a critical incident, or not, typically target individual staff within an organization through new policies, training, work-aids or compliance. These approaches often make work more difficult through excessive tasks and increased complexity. Science and practice show that staff are a source of success, not failure. Enhancing safety is achieved through removing barriers and providing supportive systems for staff to achieve organizational outcomes. Additionally, understanding where these enhancements can be added is informed by providing staff with a platform to share their knowledge and experience in a safe way.