Changing the way we investigate healthcare incidents
- English Narration version
- Korean Narration Version
- Chinese Narration Version
- Spanish Narration Version
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
Richard Clive Holman Award was given in 2019 by CIEHF for Effective Communication on the Value of Human Factors
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
There is a 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. 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).
- Canham, A, Jun, GT, Waterson, PE, Khalid, S (2018) Integrating systemic accident analysis into patient safety incident investigation practices, Applied Ergonomics, 72, ISSN: 1872-9126. DOI: 10.1016/j.apergo.2018.04.012.
- Ibrahim Shire, M, Jun, GT, Robinson, SL, (2018) The Application of System Dynamics Modelling to System Safety Improvement: present use and future potential, Safety Science, 106, pp.104-120, ISSN: 0925-7535. DOI: 10.1016/j.ssci.2018.03.010.
- Kee, D, Jun, GT, Waterson, P, Haslam, R, (2016) A systemic analysis of South Korea Sewol ferry accident – Striking a balance between learning and accountability, Applied Ergonomics: human factors in technology and society, ISSN: 1872-9126. DOI: 10.1016/j.apergo.2016.07.014.
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