Pa Patient Saf Advis 2017 Dec;14(4).
Saves, System Improvements, and Safety-II
Critical Care; Internal Medicine and Subspecialities; Nursing; Pediatrics; Surgery
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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.1

Standardization: a Double-Edged Sword

The following events were reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS)* and illustrate how process standardization is not inherently good or bad. These contrasting event reports show that standardization can be a powerful tool, but must be applied thoughtfully.

A laboratory test was ordered because of concerns about contamination of a previous specimen. When the provider looked for the results in the computer, he saw that the test had been cancelled because the test was ordered too soon following the previous test; the automatic cancellation process was designed to prevent test duplication. The facility will review its test-duplication policies.

A surgeon was performing an emergency procedure and requested the equipment tray. The tray did not contain specific items that she required. Investigation revealed that there are multiple versions of the equipment tray, which contain different instruments. The facility will standardize the equipment tray going forward.

These juxtaposed examples demonstrate that the value and safety of standardization depend on circumstances. In one case, standardization—possibly intended to avoid unintentional duplication—interfered with clinically indicated patient-care processes. In the other case, lack of standardization resulted in process inefficiency that might have been avoidable. Thoughtful implementation of standardization includes consideration of the risks and benefits of standardization in specific contexts and acknowledgment that unanticipated circumstances or unintended consequences are possible.

Both facilities are to be commended for addressing these events with system-wide interventions.

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


  1. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015 Oct;27(5):418-20. Also available: PMID: 26294709.

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