Changing the way we investigate healthcare incidents

170914 Systems Thinking Big Picture

You can download the big picture image poster above for A1 printing (PDF: 170914 Systems Thinking Big Picture).

Loughborough University Press releasesThe NHS should alter the way it investigates cases of serious failures involving patient care

There is growing awareness of the problems of Root Cause Analysis (RCA) in healthcare. RCA promotes a flawed reductionist view, which can easily create blame culture and resultant remedial actions focusing only on staff retraining (Peerally, et al, 2016; Kellogg, et al, 2016; Trbovich, et al, 2017). Managers and clinicians in healthcare have limited awareness of alternative systemic analysis approaches, which have been established in other high risk industries like aviation, rail and oil & gas.

What really matters is the way we think and here are some system diagrams which can facilitate our systems thinking (interaction-focused).

  1. AcciMap (Accident Mapping)
  2. Hierarchical Safety Control Structure Diagram
  3. Causal Loop Diagram


  1. Peerally, MF, Carr, S., Waring, J., Dixon-Woods, M. (2016) The problem with root cause analysis, BMJ Quality & Safety; 26 (5) 417-422
  2. Kellogg, KM., Hettinger, Z.,  Shah, M., Wears, RL., Sellers, CR., Squires, M., Fairbanks, RJ. (2016) Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? 
  3. Trbovich, P., Shojania, KG. (2017) Root-cause analysis: swatting at mosquitoes versus draining the swamp, 

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Praise for the animation