{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T06:01:52Z","timestamp":1785132112943,"version":"3.55.0"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T00:00:00Z","timestamp":1785110400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"<jats:p>Healthcare organizations increasingly investigate patient safety incidents using systems thinking. However, even investigations that claim to adopt a systems approach frequently revert to linear, event-focused reasoning concluding on deviations and recommending further training. A foundational question remains unresolved: when an incident review identifies a \u201cdeviation,\u201d does this represent exceptional behavior or the system's typical mode of operation that generally succeeds under varying conditions but occasionally fails? Without this distinction, explanations for incidents tend to focus on individual non-compliance rather than understanding the everyday adaptations that enable care delivery in a complex adaptive system. Consequently, incident reviews that promote system learning often continue to recommend retraining, reminders, and reinforced compliance. In this Perspective, we propose a Safety-II model for incident review structured around three analytical lenses: work-as-imagined, work-as-done, and work-as-experienced\u2014the last capturing what only patients and families can witness, longitudinally, across settings and professional boundaries. We introduce a prevalence-indexed analysis of work-as-done, in which longitudinal electronic medical record and operational data are used to establish whether a flagged practice represents exception or norm, while remaining transparent about the gap between documented and enacted work. We position this contribution alongside recent advances in incident analysis and patient partnership, and set out concrete proposals for regulators, healthcare organizations, and researchers.<\/jats:p>","DOI":"10.3389\/frhs.2026.1884750","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T05:41:14Z","timestamp":1785130874000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Rethinking learning from incidents in healthcare: a Safety-II model integrating work-as-imagined, work-as-done, and work-as-experienced"],"prefix":"10.3389","volume":"6","author":[{"given":"Nawal","family":"Khattabi","sequence":"first","affiliation":[{"name":"Primary Health Care Corporation","place":["Doha, Qatar"]},{"name":"Faculty of Health, Plymouth University","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Axel","family":"Ros","sequence":"additional","affiliation":[{"name":"J\u00f6nk\u00f6ping Academy for Improvement of Health and Welfare, School of Health and Welfare, J\u00f6nk\u00f6ping University","place":["J\u00f6nk\u00f6ping, Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Carey","sequence":"additional","affiliation":[{"name":"Faculty of Health, Plymouth University","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aled","family":"Jones","sequence":"additional","affiliation":[{"name":"Faculty of Health, Plymouth University","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,27]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"371","DOI":"10.1177\/0091270004273680","article-title":"Origin and uses of primum non nocere\u2014above all, do no harm!","volume":"45","author":"Smith","year":"2005","journal-title":"J Clin Pharmacol"},{"key":"B2","volume-title":"Notes on Hospitals","author":"Nightingale","year":"1863"},{"key":"B3","volume-title":"To Err Is Human: Building a Safer Health System","author":"Donaldson","year":"2000"},{"key":"B4","volume-title":"Still Not Safe: Patient Safety and the Middle-Managing of American Medicine","author":"Wears","year":"2020"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1736","DOI":"10.1377\/hlthaff.2018.0738","article-title":"Two decades since to err is human: an assessment of progress and emerging priorities in patient safety","volume":"37","author":"Bates","year":"2018","journal-title":"Health Aff (Millwood)"},{"key":"B6","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1136\/bmjqs-2016-005511","article-title":"The problem with root cause analysis","volume":"26","author":"Peerally","year":"2017","journal-title":"BMJ Qual Saf"},{"key":"B7","doi-asserted-by":"publisher","first-page":"350","DOI":"10.1136\/bmjqs-2016-006229","article-title":"Root-cause analysis: swatting at mosquitoes versus draining the swamp","volume":"26","author":"Trbovich","year":"2017","journal-title":"BMJ Qual Saf"},{"key":"B8","doi-asserted-by":"publisher","first-page":"524","DOI":"10.1159\/000508677","article-title":"How much of root cause analysis translates into improved patient safety: a systematic review","volume":"29","author":"Martin-Delgado","year":"2020","journal-title":"Med Princ Pract"},{"key":"B9","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1093\/intqhc\/mzaa009","article-title":"Using Safety-II and resilient healthcare principles to learn from never events","volume":"32","author":"Anderson","year":"2020","journal-title":"Int J Qual Health Care"},{"key":"B10","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1136\/bmjqs-2025-019063","article-title":"Do patient safety incident investigations align with systems thinking? 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