Changing the way we investigate healthcare incidents
Award-Winning Animation: Systems Thinking – A New Direction in Healthcare Incident Investigation 
- 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
Great YouTube video on systems thinking in healthcare and #patientsafety @gcThomasJun @lborouniversity https://t.co/ifWyAVXmAf
— 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
Almost ready to start workshop on action planning after investigations and will be making use of @gcThomasJun educational materials @CV_UHB
— Maria Roberts (@maria_oaktree) September 21, 2017
Great short video from @gcThomasJun explaining Systems Thinking in healthcare investigations https://t.co/WjXgoD1uEI
— NHS Patient Safety (@ptsafetyNHS) 9 October 2017
This is great well done @gcThomasJun @PatrickWaterso1 simple representation of system thinking. Excellent resource to open conversations https://t.co/3r4pGXiX4y
— 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
Just 3mins of ur day – Watch this film! – gr8 work progressing how we can really #learn from #patientsafety #incidents @LPTnhs @LIIPSLeics https://t.co/yOTX7eFMQQ
— 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).
References
- 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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