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Institutional resilience in healthcare systems
  1. J Carthey1,
  2. M R de Leval1,
  3. J T Reason2
  1. 1Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH and the Institute of Child Health, London WC1N 1EH, UK
  2. 2Psychology Department, The University of Manchester, Manchester M13 9PL, UK
  1. Dr J Carthey, Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK j.carthey{at}

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A recent report for the President of the United States described the impact of preventable medical errors as a “national problem of epidemic proportions”.1 Similar concerns have been echoed in the report of an expert group chaired by the Chief Medical Officer.2 In this report it was estimated that 400 people in the UK die or are seriously injured each year in adverse events involving medical devices, and that harm to patients arising from medical errors occurs in around 10% of admissions—or at a rate in excess of 850 000 per year. The cost to the NHS in additional hospital stays alone is estimated at around £2 billion a year.

The positive face of safety

Safety has two faces. The negative face is very obvious and is revealed by adverse events, mishaps, near misses, and so on. This aspect is very easily quantified and so holds great appeal as a safety measure. The other, somewhat hidden, aspect offers a more satisfactory means of assessing safety. This positive face can be defined as the system's intrinsic resistance to its operational hazards. Some organisations will be more robust in coping with the human and technical dangers associated with their daily activities. This will be as true for healthcare institutions as it is for other systems engaged in hazardous activities. In short, some organisations will be in better “safety health” than others.

The safety space

The ideas of resistance and vulnerability can be represented as the extremes of a notional space termed the “safety space” (fig 1). The horizontal axis of the space runs from an extreme of maximum attainable resistance (to operational hazards) on the left to a maximum of survivable vulnerability on the right. A number of hypothetical organisations are located along this resistance vulnerability dimension. The cigar-shaped space shows that most organisations will occupy an approximately …

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