Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management

J T Reason, J Carthey, M R de Leval
2001 BMJ Quality & Safety  
essential prerequisite to effective risk management Diagnosing "vulnerable system syndrome": an http://qhc.bmjjournals.com/cgi/content/full/10/suppl_2/ii21 Updated information and services can be found at: These include: References http://qhc.bmjjournals.com/cgi/content/full/10/suppl_2/ii21#otherarticles 5 online articles that cite this article can be accessed at: Abstract Investigations of accidents in a number of hazardous domains suggest that a cluster of organisational pathologies-the
more » ... rable system syndrome" (VSS)-render some systems more liable to adverse events. This syndrome has three interacting and self-perpetuating elements: blaming front line individuals, denying the existence of systemic error provoking weaknesses, and the blinkered pursuit of productive and financial indicators. VSS is present to some degree in all organisations, and the ability to recognise its symptoms is an essential skill in the progress towards improved patient safety. Two kinds of organisational learning are discussed: "single loop" learning that fuels and sustains VSS and "double loop" learning that is necessary to start breaking free from it. (Quality in Health Care 2001;10(Suppl II):ii21-ii25) Keywords: vulnerable system syndrome; risk management; patient safety; learning Quality in Health Care 2001;10(Suppl II):ii21-ii25 ii21 Psychology Department,
doi:10.1136/qhc.0100021.. fatcat:rzgvgm4zxvgnroxllv4wb5bltu