Resource Library-Work in Action: Understanding Human Error and Operationalizing Safety Science to Impact Safety Culture and Reduce Patient Harm in Healthcare

Video Transcription

Video Summary

MedStar Health leaders Terry Fairbanks and Kate Kellogg argue that healthcare safety progress since the IOM reports has been too slow and requires disruptive change grounded in true safety science, not just traditional quality improvement. They describe MedStar’s context (10 hospitals, strong human factors program, open communication and caregiver support) and present findings from interviews and crowdsourced input from global safety experts that produced five needs: stop conflating quality and safety competencies, deliberately infuse safety science (not “pseudo” safety), shift resources toward proactive risk identification, rethink safety/just culture, and engage the entire healthcare industry in a systems approach.<br /><br />Fairbanks emphasizes that quality work (Lean, Six Sigma, metrics optimization) differs from safety work (complex systems theory, Safety-I/II, human factors, resilience, culture). Promoting strong quality leaders into safety roles without safety training undermines progress.<br /><br />Kellogg explains human performance principles: humans are inherently fallible; error types include knowledge-based, rule-based, and most commonly skills-based slips/lapses. Understanding error type is essential because common healthcare “fixes” like education and labels often don’t prevent slips/lapses; system redesign does. She connects this to just culture, distinguishing normal error, at-risk behavior (often driven by drift/normalized deviance), and rare reckless behavior, with shared accountability between individuals and organizations.<br /><br />Fairbanks describes an operational model mirroring primary/secondary/tertiary prevention: design for safety, proactively mitigate existing hazards, and react effectively to events with transparent communication and robust event reviews. MedStar added leadership “hard stop” huddles before discipline to prevent just-culture violations. Both conclude that vendors, regulators, IT, pharma, and device makers must partner—like aviation’s CAST model—to engineer safer systems.

Asset Caption

Speakers: Terry Fairbanks, MD, MS, Kate Kellogg, MD, MPH

Join us for an insightful session delving into the critical distinction between types of human error in healthcare, and how the science of safety and understanding of system interactions can lead healthcare to a true state of high reliability. Led by two safety science and human factors experts from MedStar Health, we’ll explore what safety science tells us about managing human error in complex human-technology systems, and linking this to safety culture. The speakers will offer reflections on operationalizing just culture, reducing human error, mitigating the impact of error, and using a proactive approach to allow these mitigations to occur before patients are harmed.

Meta Tag

Competency Tag PS2

Competency Tag Description Apply safety science principles and methods to healthcare quality and safety work, leveraging safety curriculum and competencies to promote teamwork.

Domain Tag Patient Safety

Keywords

healthcare safety science

MedStar Health

quality improvement vs safety

human factors engineering

Safety-I and Safety-II

just culture and accountability

human performance and error types

proactive risk identification

resilience engineering in healthcare

systems approach to patient safety