Elsevier

Applied Ergonomics

Volume 72, October 2018, Pages 1-9
Applied Ergonomics

Integrating systemic accident analysis into patient safety incident investigation practices

https://doi.org/10.1016/j.apergo.2018.04.012Get rights and content

Highlights

  • Systems approach can improve current healthcare incident investigation outputs.

  • Systems approach produces system-level recommendations for long-term changes.

  • Systems approach produce change management-related recommendations.

  • Human factors expertise is needed to apply systemic approach in healthcare.

  • Integration of HFE method and expertise can be done without huge investment.

Abstract

There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual–based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Introduction

High risk industries such as aviation, nuclear, rail and healthcare use accident and incident investigation to learn from failure and create action plans to avoid future incidents (Salmon et al., 2011). Within healthcare there is growing awareness of issues with current practice in incident investigation, with questionable quality of investigations and analysis resulting in ineffective recommendations and action plans (Wu et al., 2008; Peerally et al., 2016; Kellogg et al., 2016). Limitations identified include an over reliance on the promotion of a single flawed reductionist approach, Root Cause Analysis (RCA) and a lack of utilisation of external safety expertise (Wu et al., 2008; Peerally et al., 2016; Kellogg et al., 2016). Human Factors and Ergonomics (HFE) has developed expertise in systems safety and applied various systemic approaches to incident analysis. HFE's systemic accident analysis and system design approaches have been developed for use in complex work systems (Leveson, 2012; Hollnagel, 2012; Rasmussen, 1997) and are judged to be better suited to forming an understanding of accidents in complex high-risk industries, as compared to traditional causal event chain techniques, such as Root Cause Analysis (Salmon et al., 2011; Leveson, 2004; Hollnagel, 2004).

The potential of systemic accident analysis in healthcare such as Systems-Theoretic Accident Model and Processes (STAMP) (Leveson, 2004), AcciMap (Rasmussen and Svedung, 2000) and Functional Resonance Analysis Method (FRAM) (Hollnagel, 2012) has been demonstrated through analysis undertaken by experienced external method experts (e.g. Leveson et al., 2016; Karsh et al., 2014; Alm and Woltjer, 2010). However, systemic accident analysis has had little exposure to healthcare stakeholders that undertake incident investigations in current healthcare practice. A potential avenue for HFE to have a beneficial impact on healthcare is by facilitating healthcare stakeholders to apply systems approaches to their incident investigation (Waterson and Catchpole, 2016).

The current study aims to investigate the application of an HFE-led systems approach to healthcare incident analysis. Taking into account the time constraints of healthcare stakeholders the study asks how collaboration between HFE and healthcare can facilitate system thinking and guide analysis towards recommendations of more effective remedial actions.

Section snippets

Setting

The study is centred on a medication error incident (an insulin overdose case from a prescription error) involving two healthcare providers in the UK serving a population of around one million; an acute trust employing over 14,000 staff with a 900-bed hospital and a trust providing community health services which employs over 5000 staff. The incident involved a patient being administered an overdose of insulin on three occasions following a drug prescription error. Drug prescription errors have

Processes – Comparison between HFE-led STAMP and current practice RCA

Key information from the RCA and STAMP processes is presented in Table 2. Along with the different analysis methods used, there were differences in the people involved, their areas of expertise and the approach to group work. The timescales set for completion of the investigation in the UK policy is 60 working days including 15 days for internal governance approval. The actual time taken for the RCA process for this case was not recorded, but the team usually carry out investigation whilst

Discussion

This study has applied an HFE-led systemic accident analysis approach to healthcare incident analysis and demonstrated STAMP's potential in healthcare. The use of STAMP and collaboration between HFE and healthcare stakeholders was found to facilitate systems thinking, impacting the thinking of some of the original investigators of the incident and guided the development of underlying system-based recommendations.

Conclusions and future research

The present study raises the possibility that HFE expert-facilitated systemic accident analysis with healthcare stakeholders can enable effective and efficient patient safety incident investigation identifying remedial actions on underlying system issues beyond individual issues. This study offers insights into how human factors expertise and approach can be integrated into patient safety incident investigation practice.

This study is limited in having a single case study design, multiple case

Acknowledgements

The authors would like to thank Leicestershire Improvement, Innovation and Patient Safety Unit (LIIPS) for their support in organising the workshops and the workshop participants for their inputs. We also would like to thank Dr Diane Ketley for her comments on the paper.

References (31)

  • L.J. Hettinger et al.

    Modelling and simulation of complex sociotechnical systems: envisioning and analysing work environments

    Ergonomics

    (2015)
  • E. Hollnagel

    Barriers and Accident Prevention

    (2004)
  • E. Hollnagel

    Resilience – the challenge of the unstable

  • E. Hollnagel

    FRAM, the Functional Resonance Analysis Method: Modelling Complex Socio-technical Systems

    (2012)
  • K. Ishikawa

    Guide to Quality Control

    (1982)
  • Cited by (41)

    • Data-driven determination of collapse accident patterns for the mitigation of safety risks at metro construction sites

      2022, Tunnelling and Underground Space Technology
      Citation Excerpt :

      Respondents or interviewees are usually biased regarding sensitive safety information related to themselves (Payre and Diels, 2020). It is widely acknowledged that accident investigation can provide valuable information for preventing industrial workers from similar workplace accidents (Canham et al., 2018; Chua and Goh, 2004). Accident data-driven safety risk analysis is able to effectively improve safety performance at organizational or industry levels (Pagell et al., 2015).

    • Systems theoretic accident model and process (STAMP): A literature review

      2022, Safety Science
      Citation Excerpt :

      Altabbakh et al. (2014) verified the practicality and validity of the STAMP in the oil and gas industry through the accident case analysis and pointed out that the model exceeds traditional analysis methods (e.g., hazard and operability analysis, HAZOP). Canham et al. (2018) adopted STMAP to analyse a medication error incident in the U.K. to discuss integrating systems analysis models into patient safety incident investigation. The study reflected the potential of STAMP in the healthcare system.

    • Causes of use errors in ventilation devices - Systematic review

      2022, Applied Ergonomics
      Citation Excerpt :

      The issues were systematically listed in a cause-and-effect diagram by the occurring main categories (Fig. 2). Deviating from widespread categorizations, e.g. the 6 M method (man, machine, method, milieu, materials, management) (Canham et al., 2018; Wilken et al., 2017), the main influencing factors were adopted to best match the aspects found. The main categories (root cause areas) cover different aspects of the design of the user interface and the context of use.

    View all citing articles on Scopus
    View full text