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Review
. 2021 Aug;21(8):307-313.
doi: 10.1016/j.bjae.2021.03.004. Epub 2021 Apr 28.

Systems-based models for investigating patient safety incidents

P Sampson  1 , J Back  2 , S Drage  2   3
Affiliations
Review

Systems-based models for investigating patient safety incidents

P Sampson et al. BJA Educ. 2021 Aug.
No abstract available

Keywords: complex systems; incident analysis; patient safety.

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Figures

Fig 1
Fig 1
The hierarchy of effectiveness. This diagram depicts the effectiveness of various strategies for modifying behaviour. The framework deems person-based approaches less effective than ones targeted at the system level. Although culture change may have the most long-lasting effect, it is the most difficult to implement. A forcing function is an aspect of a design that prevents an unintended or undesirable action from being performed or allows its performance only if another specific action is performed first (e.g. special Luer-lock syringes that only connect to specific spinal needles). Adapted with permission from ISMP Canada: https://www.ismp-canada.org/download/ocil/ISMPCONCIL2013-4_EffectiveRecommendations.pdf.
Fig 2
Fig 2
SEIPS 2.0 applied to the ICU work system after an incident involving a retained central venous catheter guidewire. SEIPS 2.0 can be applied to determine work system factors that may have influenced an incident occurring. Each work system elements contains factors that are thought to be relevant to the incident occurring. The diagram depicts that all factors interact with each other. Specific elements have a direct interaction and may be ones to focus on during an investigation, example interactions are depicted by dashed green lines. The feedback loops indicate that changes in the work system can occur as healthcare organisations collect, analyse, and use process and outcome data. CVC, central venous catheter.
figS1
figS1
See this image and copyright information in PMC

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