Seeing What's There: Reshaping Event Reviews with Safety-ii Principles

Session Description: As healthcare grows more complex, it becomes increasingly critical that we approach infection prevention in new and innovative ways. First practiced as a response to workplace injuries in industry, Safety-II shifts focus to the "work-as-done" as opposed to the "work-as-imagined" by leveraging the lived experience of frontline staff to drive adaptive discussions and practical solutions. Traditionally, retrospective reviews are performed when a hospital-acquired infection is identified, but we limit our learning by focusing only on a single event. Even in procedures that go well, the workarounds and adjustments made by frontline workers in the course of their daily tasks can prove to be systemic sources of risk. Often overlooked and poorly understood, investigating "work-as-done" through a broad and holistic lens enables a more thorough and robust analysis of root cause. By employing the concepts of Safety-II and Learning Teams, our department examined long-standing processes through a proactive, non-event based, team member-centric perspective, which resulted in materially different remedies. Our learning teams focused on surgical site infections and catheter-associated urinary tract infections to discover hidden barriers and engage team members in developing sustainable solutions. This workshop encapsulates these efforts with the intent to equip infection preventionists with tangible strategies to recontextualize their own event reviews through the framework of the 4 D's – Dumb, Dangerous, Difficult, and Different. Participants will be able to practice facilitating learning teams and applying Safety-II concepts in order to look past theory and understand healthcare as it is actually performed. This activity is intended for infection preventionists responsible for leading event reviews and quality improvement initiatives.