Table 1.

Selected safety science schools of thought and relevance for healthcare safety investigations

Perspectives	Relevance for healthcare safety investigations
Energy and barriers	Individual, technical, cultural and organizational barriers hinder accidents from developing and escalating Questions for consideration What risks must be identified and managed? How did the organization establish barrier systems? Independent barriers? Multiple barriers? Technical barriers? How did the organization allocate responsibility to maintain and update barriers?
Normal accidents	Accidents are normal, will happen and are caused by the complexity of the system Questions for consideration Was the system functionally designed to handle its risks? Tight or loose couplings? Linear or complex interactions? Centralized or decentralized decision-making? Base on your findings Do procedures fit this system–or does it need flexibility and distributed decision-making?
High reliability	Organizing for safety is first priority Questions for consideration How did the organizations focus on creating redundancy, safety culture and learning mechanisms? To what degree was decision-making distributed to people with expertise? To what degree did the organization have overlapping competence, personnel and perspectives to understand and handle risks? What kind of training philosophy and practice existed?
Information management	Information is key to understand and learn from accidents, and requires information management mechanisms Questions for consideration What were the cultural beliefs and assumptions in the organization? What kind of warning signals had been raised? How easy was it to raise warnings? What mechanisms existed to report and learn from adverse events? Did leaders welcome critical input? What was the status of power balance, hierarchies, information sharing deficiencies over years? Accidents usually incubate over time–How was it possible?
Decision-making	There are always numerous and simultaneous priorities. Risk and safety need to be balanced in goal conflicts with productivity and efficiency demands Questions for consideration What kind of internal and external pressure existed on staff, managers and regulators? Financial demands? Change processes? Work-load demands? Were safety margins at risk? Any help or hinder from external demands, stakeholders, and environmental conditions? Safety is a multi-level phenomena Who were the key stakeholders at micro-, meso- and macro-level? How did stakeholders’ decisions influence risk? How was risk managed in organizational interfaces? How did the organization handle change processes, reforms and implementation processes?
Resilience engineering	Focus on daily work practice. Study how work normally goes well and use it as a basis for understanding why it sometimes fail Questions for consideration What are the key functions for normal work practice? How is work usually done? What key constraints must be in place? (time, resources and competence) What systems help monitor and inform work performance? To what degree is adaptive capacity important for the work? Was adaptive capacity considered positive or negative for safety?