Changing the way we investigate healthcare incidents

Award-Winning Animation: Systems Thinking – A New Direction in Healthcare Incident Investigation 170914 Systems Thinking Big Picture

You can download the big picture image poster above for A1 printing (PDF: 170914 Systems Thinking Big Picture).

Loughborough University Press releasesThe 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

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).

  1. AcciMap (Accident Mapping)
  2. Hierarchical Safety Control Structure Diagram
  3. Causal Loop Diagram


  • Canham, A, Jun, GT, Waterson, PE,  Khalid, S (2018) Integrating systemic accident analysis into patient safety incident investigation practicesApplied 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 potentialSafety 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 accountabilityApplied Ergonomics: human factors in technology and society, ISSN: 1872-9126. DOI: 10.1016/j.apergo.2016.07.014.

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