Designing a ‘systems’ error classification framework to aid investigation of critical incidents in patient care settings

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Analysis of serious incidents occurring within patient care settings guides change implementation within the work system. However frequently changes ‘miss the mark’ resulting in, cost, manpower and time while tangible reductions in risk remain absent.

While changes are made in an attempt to ‘engineer out’ opportunities for error highlighted by investigatory tools, recorded levels of recurring ‘new incidents for old reasons’ highlight methodologies may only be adequate for detecting ‘highly visible’ failures existing at the work system surface This results in the true cause of error remaining invisible and active (Irwin et al., 2011; Johnson, 2003; NHS. 2015).

Root Cause Analysis is the tool of choice within the NHS for ascertaining how, where, what and why things go wrong. However the RCA framework as it is presented in healthcare departs from the tools origin and established industrial use as a structured framework for diagnosing system failings. This is perhaps most evident with human factors (HF) influencers positioned as a separate component of risk, existing independent from failings in technical execution of tasks. Largely this weights the classification of human factors as contributory towards incidents as opposed to causal. Where HF categories are present, these focus almost exclusively on identifying constraints within communications and teamwork domains. Wider psychological and environmental influences of stress and strain, job demand and control, task scheduling, distraction and memory are not included beyond how they influence communications and teamwork.

The importance of learning from critical incidents cannot be overstated; the 2013-14 report from the Public Administration Select Committee for NHS England asserts over 12’000 avoidable hospital deaths occur a year, in addition to a further 10’000 serious incidents and 1.4 million ‘low-harm reported’ incidents. The Secretary State for Health puts the number of ‘never events’ (e.g. wrong site surgery) at 338 occurrences, while the NHS Litigation Authority’s latest estimate of clinical negligence liabilities sits at £26.1 billion.

The Quality, Reliability, Safety and Teamwork Unit (QRSTU) aims to deliver a novel error classification framework compatible with systematic RCA methodology. The systems-led framework will give equal diagnostic weighting to ergonomic, environmental, task, cultural and individual factors alongside interpersonal domains, resulting in a structured model for analysing serious incidents. The goal is to ‘make visible’ root-causes and contributors to error currently left ‘invisible’ by existing approaches in favour of easier diagnosed but ultimately low-impact ‘quick-wins’. The framework will allow for diverse root-causes to error to be traced and guide interventions to the correct process stage error originates from, saving money, time and manpower while facilitating learning from error and reducing patient harm.

Date & time

7-8 June 2016

NCTL Learning and Conference Centre, Nottingham

What is a Complex System?

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