Changing the way we investigate healthcare incidents
You can download the big picture image poster above for A1 printing (PDF: 170914 Systems Thinking Big Picture).
Loughborough University Press releases: The 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;. 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).
- Peerally, MF, Carr, S., Waring, J., Dixon-Woods, M. (2016) The problem with root cause analysis, BMJ Quality & Safety; 26 (5) 417-422
- Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
Root-cause analysis: swatting at mosquitoes versus draining the swamp,
You can find the animation on both YouTube and Vimeo. Please, click the icon below.
English narration version – Subtitles available in English, Spanish, Korean and Chinese
Praise for the animation
If you care about safety in healthcare, and you want to understand why healthcare in the US isn’t becoming safer, watch this video. https://t.co/AkobLxcrWA
— RJ ‘Terry’ Fairbanks (@TerryFairbanks) 15 September 2017
The ever brilliant Thomas Jun with a short video explaining systems thinking during investigations to improve healthcare safety…… https://t.co/vKYzBzN5Or
— Martin Bromiley (@MartinBromiley) 15 September 2017
— Pascale Carayon (@carayonp) September 14, 2017
Excellent, thanks for sharing. Teaching medication related adverse events next week to med students and will use.
— Heather Murray (@HeatherM211) September 15, 2017
— Maria Roberts (@maria_oaktree) September 21, 2017
— NHS Patient Safety (@ptsafetyNHS) 9 October 2017
— Tracy Ward (@Wardtracyward) September 14, 2017
Fantastic video outlining the importance of embracing system safety principles in healthcare! https://t.co/2RxzXIjLnm
— Kate Kellogg (@KateKelloggMD) September 15, 2017
— Richard Apps (@richard_apps) September 15, 2017