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

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Nick Adams, University of Oxford

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.

Date & time

7-8 June 2016

NCTL Learning and Conference Centre, Nottingham

What is a Complex System?

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