Resilience Engineering Concepts, Safety-II Language, FRAM Practice, and Co-Creating Communities: How Hollnagel Reshaped Patient Safety

This paper examines Erik Hollnagel’s legacy in reshaping patient safety through four interconnected dimensions: Resilience Engineering concepts, Safety-II language, the Functional Resonance Analysis Method (FRAM) as practice, and the co-creation of communities. Patient safety developed around linear models of error and compliance. Hollnagel’s work introduced a systems-based alternative. Resilience Engineering provided new conceptual foundations, reframing safety as a property of healthcare systems shaped by everyday performance variability and adaptive capacity. Concepts such as the Efficiency-Thoroughness Trade-Off (ETTO) and resilience potentials offered fresh ways of understanding how clinicians sustain safe care under pressure. Safety-II translated these insights into an accessible language, with terms such as work-as-imagined versus work-as-done, performance variability, and learning from what goes well. The rhetorical contrast with “Safety-I”, though contested, offered a provocative narrative that helped practitioners and policymakers reframe safety. The FRAM operationalised these ideas in investigations and improvement work, enabling healthcare teams to model interdependencies, illuminate system dynamics, and understand how everyday adaptations both sustain and threaten safe outcomes. Equally important has been Hollnagel’s role in cultivating healthcare-focused communities such as the Resilient Health Care Society, the Safety-II in Practice workshops, and the FRAMily. These communities have provided interpretive spaces for translating abstract principles into clinically meaningful insights, while guarding against superficial adoption and supporting sustained learning and capability development. Hollnagel’s enduring contribution is not a fixed doctrine nor a set of prescriptive interventions, but a reframing of patient safety —expanding its repertoire beyond compliance and error management towards managing safely as a dynamic, collective achievement.