PA Patient Saf Advis 2017 Jun;14(2):84
Saves, System Improvements, and Safety-II
Critical Care; Emergency Medicine; Radiology
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​"Saves, System Improvements, and Safety-II" is an occasional feature in the Pennsylvania Patient Safety Advisory, highlighting successes of healthcare workers in keeping patients safe. The Safety-II approach assumes that everyday performance variability provides adaptations needed to respond to varying conditions and that humans are a resource for system flexibility and resilience.

An Unexpected Problem: Was the Response Correct?

The following event report was submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS):*

A patient arrived for a routine after-hours radiologic study and expressed that she was not feeling well. As the study began, she indicated that she was having trouble breathing. The technician noted a decreasing oxygen saturation, and the patient described increased difficulty breathing. The technician placed the patient on oxygen according to the organization's [emergency response] policies and called 911. The technician monitored the patient until the ambulance crew arrived and took responsibility, and the patient was transported to an acute care facility. The facility praised the technician for acting promptly and correctly.

Healthcare providers sometimes encounter situations in which they respond to a patient's unexpected deterioration but are unsure whether their actions were too aggressive. This technician may have wondered whether his or her actions on the patient's behalf were medically correct and, further, whether those actions might prompt a reprimand for disrupting a scheduled study. This report provides an important example of reinforcing correct actions. Learning from failures and errors is important, but successes also provide learning opportunities. Learning from success is particularly important when learners are unsure whether the success is a result of their abilities and efforts or occurred as a lucky outcome; such learning is important when the cost of errors is high.1 The Pennsylvania Patient Safety Authority applauds this facility for supporting the technician and for sharing their actions through PA-PSRS.


* The details of the PA-PSRS event narrative in this article have been modified to preserve confidentiality.


  1. Ellis S, Davidi I. After-event reviews: drawing lessons from successful and failed experience. J Appl Psychol. 2005 Sep;90(5):857-71. Also available: PMID: 16162059.

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