Organizational and Cognitive Psychology Models Provide Useful Insight

Models from organizational and cognitive psychology are useful in explaining the persistence of unsafe practices in everyday work.1

Reason’s model of Vulnerable System Syndrome

Describes a cluster of “organizational pathologies” (blame, denial and the pursuit of financial, as opposed to safety excellence goals) interacting with one another to make some systems vulnerable to unsafe practices and harm events.1

Tucker and Edmonston

Concept that puts forward the “quick fix” theory of first order problem solving where healthcare providers respond with solutions that provide short term resolutions.1

Amalberti’s Theory of Migration to Boundaries

Theorizes that people work outside established zones of safe practice resulting in competent, highly motivated and caring healthcare providers “working around regulations” that are in place to protect patients from harm.1

1. Espin SL, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Quality and Safety in Health Care 2006; 15: 165-170.