Our research team has carried out extensive research on applying a systems approach to accident analysis across a variety of sectors – marine, rail, food as well as healthcare. We had many opportunities to review and analyse various accident reports. Every accident story is painful, but it is even more so when we found that ineffective remedial actions were recommended after the accident investigation and the same things happen again and again.
We are aware that there are many factors influencing the way accidents are analysed and remedial actions are decided as Lundberg, et. al (2010) very helpfully summarised in his paper, ‘What you find is not always what you fix – How other aspects than causes of accidents decide recommendations for remedial actions.’
As a starting point, we are very keen to promote systems thinking in healthcare incident investigations and support healthcare staff who are involved in accident investigations in their local settings. Thanks to the funding from the Health Foundation’s Evidence into Practice Programme, which aimed to bridge the gap from academic research findings to actionable information for people practicing in the field, we were able to work with many world-leading experts in their fields (safety science, healthcare, visual communication, scriptwriting) and produce a 3 minute 20 sec animation: Systems Thinking – a New Direction in Healthcare Incident Investigation.
We hope that the animation can provide a helpful reminder for systems thinking whenever healthcare teams start their new accident investigation. We also hope that the animation can challenge the current thinking of a wider group of stakeholders working at the clinical, management, commissioning and policy-making level in healthcare.
We would like to briefly share the animation making process and our short reflections as researchers, which might be helpful to those who might want to use the animation for their research dissemination in future.
Sep 2017
Gyuchan Thomas Jun
Message/Outline
The project team started with the reflection on our past research findings. Through a team brainstorming session, we drafted overarching message and sub-messages. We decided to use the insulin overprescription case as an illustrative example, of which we were involved in reviewing/reanalysing the real incident report. We then produced PPT slides to show our messages/example to get inputs from safety experts and healthcare professionals.
We ran two one-hour sessions; one with a group of the world-leading safety experts who mainly worked in non-healthcare domains (aviation, rail, etc); the other with a group of healthcare professionals. We received valuable inputs based on their extensive experiences concerning both contents and presentation of the messages and example.
Reflections: Our initial draft had too many messages for a 3-4 minute animation. The length of the animation (3-4 minute) was chosen considering an expected attention span for this kind of animation. It was okay to start with many messages but we were able to refine and prioritise messages through the stakeholder feedback sessions. We asked healthcare professionals regarding appropriate tone of the narration, level of provocation. We agreed that it is good to provoke our target audience, but we don’t want to upset them.
Script Writing
We had a half day creative meeting with illustrators and a script writer. We presented our final messages and outline to them. It was a long Q&A session. The script writer sent us a draft script in a week and we refined it through several iterations. The final script is attached at the bottom of this page.
Reflections: We had experience of writing a script for animation ourselves in the previous animation (Two contrasting views of ..), but it was really good to work with a professional script writer. The script writer was ruthless in cutting contents down to 3 min script, but still effectively included many important messages. The script writer got the main message right, but we actually changed more than 50% of the initial script after several iterations. It is still critical that researchers get involved in the script writing process.
Animatic
Based on the script, a team of talented visual designers created a hand-drawn storyboard and later animatic (animated storyboard) using a provisional voice-over. Through a couple of feedback sessions, the animatic evolved and became ready for the main production.
Reflections: We had a tendency to try to turn every word into dynamic elements in the animatic, but we had to rely on and listen to the intention of the visual designers.
Main Production
Hard work to the visual designers, but we waited and enjoyed watching the progress. We were involved in the voice-actor selection and recording process. Our role was not huge, but we highlighted which words need to be emphasized and where the tone of the voice should be changed.
Dissemination
Still ongoing. Please share it with many others who might benefit from watching this animation. We would welcome any advice and suggestion for further dissemination.
Full script (457 words)
English
Systems Thinking – A New Directions in Healthcare Incident Investigation
The public’s affection for the NHS is beyond question, but Healthcare is under huge pressure. Overstretched budgets, rising costs, staff shortages, increased demand, alongside new technology and innovation, all increase the likelihood of safety incidents.
With around 100 serious safety incidents reported daily across the NHS – a rate largely unchanged over the past two decades – we need to find more effective ways to guarantee patient safety.
Analyses of safety incidents have revealed a wide range of contributing factors and that blameless staff often inherit existing system problems.
For example, staff shortages can mean higher workloads, which increase turnover and create further staff shortages. Attempted alleviation through hiring temporary staff brings unfamiliarity with the workplace, which leads to more interruptions and, ironically, a workload increase. It’s fertile ground for mistakes to occur.
Systems Thinking, therefore, encourages the view that incidents are NOT usually caused by a single catastrophic decision or action but by dynamic interactions between people, tasks, technology and working conditions, including management, regulation and policy, which typically escape analysis.
Let’s take an example of a medication error – Insulin over-prescription. The diabetes specialist nurse writes the recommended dosage using an assessment form. A busy prescribing doctor misreads it and prescribes 100 units instead of 10. The outcome? The patient is discharged, but soon after readmitted to an already overworked Emergency Department.
Root Cause Analysis identifies the mistake and may recommend retraining and personal reflection by those involved. Certainly, next time, the doctor will take more care. But what if, next time, it’s a different doctor? The same incident could happen again.
Systems thinking allows us to explore the underlying dynamic interactions between people, technologies and policies within and across levels of the whole systems. It highlights a clear feedback mechanism for a purchasing team, regulatory bodies and manufacturers regarding the confusion risk in the medicine name, and requests improvement. It gives the prescribing responsibility to the specialist nurse, so that the number of potentially unsafe interactions can be reduced, regardless of changes of staff. It identifies the need for an adequate workload level and recommends staff be reminded of their responsibility to voice their queries.
As Systems Thinking relies on more than single actions by individuals, it offers an opportunity for longer term learning and lasting change. And if immediate action isn’t possible, organisations, at the very least accumulate an evidence base for future changes.
By empowering people to speak up and use their skills and knowledge to act safely, Systems Thinking places emphasis on staff as a resource for safety, rather than a potential source of problems.
If you’re looking for effective and sustainable ways to prevent patient harm from incidents, embrace and encourage Systems Thinking in your investigations.
For more information, please visit our website.
Korean
시스템적으로 생각하기 – ‘의료 사고 분석’ 어떻게 해야 하나?
우리모두 안전하면서도 양질의 의료서비스를 받고 싶어한다. 그러나 현실의 의료시스템은 큰 압박을 받고 있다. 비용이나 수요는 증가하는데 반해/ 예산은 제한되어 있고, 의료진의 수는 부족하며, 날마다 새로운 기술들이 도입되고 있다. 이 모든 것들은 의료 사고가 발생할 가능성을 증가시킨다.
영국의 경우 매일 약 100건의 심각한 의료사고가 보고되고 있지만, 지난 20년동안 개선되지 않고 있으며, 다른 선진국 실정도 비슷하다. 어떻게 하면 의료사고를 효과적으로 줄일 수 있을까?
의료 사고 관련 연구 결과들을 보면,다양한 원인들이 존재하지만, 주로 의료진 개개인이 실수하기 쉬운 열악한 환경에서 일을 해야 하는 경우가 많다.
예를 들어, 의료진의 수가 부족하면 업무량이 지나치게 증가하고, 직원은 결근이나 이직이 잦아지게 되어 결국 더 많은 의료진의 부족으로 이어지게 된다. 이 부족함을 메우려 임시 직원을 많이 고용하게 되면, 업무 환경에 익숙하지 않아 오히려 방해가 될 수 있고, 역설적이지만업무량이 오히려 더 증가하게 된다. 이런 업무환경에서 의료진의 실수는 어쩌면 이미 예정되어 있다.
시스템적으로 생각하는 것은 의료사고가 한 사람의 잘못된 판단이나 행동에 의해 발생하는 것이 아니라, 작업자, 작업내용, 작업도구 및 근무 조건과 관리, 규제 및 정책간의 다이나믹한 상호 작용에 의해 발생된다는 관점을 바탕으로 한다. 그러나 사고조사를 시스템적으로 하는 경우는 많지 않다.
예를 들어 당뇨병 치료제인 인슐린을 과대 처방한 의료사고 사례를 살펴보자. 당뇨 전담 간호사는 환자 기록란에 10단위의 인슐린 처방을 제안한다. 정신 없이 바쁜 담당 의사가 이것을 잘못 읽고 10단위 대신에 100단위로 처방한다. 그 결과로 환자는 열배나 많은 인슐린을 가지고 퇴원하게 되고, 얼마 후 심각한 저혈당 합병증으로 이미 포화상태인 응급실로 재입원하게 된다.
단순하게 원인을 분석하면, 우리는 주로 관련자들의 실수들을 지적하고, 재교육 및 개인 반성을 하도록 한다. 물론, 그 담당자들은 다음에 더 많은 주의를 기울일 것이다. 그러나 다음에 다른 의료진이 처방을 한다면 어떨까? 같은 사고가 언제든지 또 다시 일어날 수 있게 된다.
“시스템적으로 생각한다는 것”은 전체 시스템의 다양한 레벨에 있는 사람, 기술, 정책 간의 다이나믹한 상호 작용을 분석하고 개선안을 제시하는 것이다.
예를 들어 관련 정부기관, 제약업체 및 병원의 구매 팀에게 헷갈릴 수 있는 인슐린 이름의 위험성을 보고하고, 개선을 요청한다. 당뇨 전담 간호사에게는 직접 처방할 수 있는 권리를 부여하여 의사를 거치지 않으므로 잠재적으로 위험한 상호 작용의 수를 줄인다. 의료진들의 업무량을 적절한 수준으로 관리하고, 서로의 처방을 재확인하고 필요하면 의문을 제시할 수 있는 병원 환경을 조성하도록 권장한다.
시스템적으로 생각하는 것은 한 사람의 행동에 집중하는 것이 아니라, 조직이 장기적으로 학습하고, 근본적인 개선책을 찾을 수 있는 기회를 제공한다. 설사 바로 실행할 수 있는 개선안이 나오지 않아도, 적어도 장기적으로 무엇을 개선해야 할지에 대한 증거 자료들를 축적할 수 있게 된다.
시스템적으로 생각하는 것은 의료진을 환자안전 유지와 개선을 위한 중요한 자원으로 생각하고 그 자원의 지식과 역할을 최대한 활용하려고 하지, 의료진을 단순히 잠재적인 의료사고의 원인과 문제로만 보지 않는다.
결국 의료사고들로부터 환자를 보호할 수 있느냐는, 당신이 시스템적으로 생각하고, 이를 의료사고 조사에 어떻게 적용하는지에 달려 있다
더 자세한 내용을 원하시면 다음의 웹 사이트를 방문하시기 바랍니다.
Spanish
Pensamiento Sistémico – Una Nueva Dirección en la Investigación de Incidentes de Atención Médica.
Todos desean recibir atención médica de buena calidad y segura pero la atención médica se encuentra bajo una gran presión.
Presupuestos sobre exigidos, costos crecientes, escasez de personal, aumento de la demanda, en conjunto con la nueva tecnología y la innovación, todo esto incrementa la probabilidad de incidentes de seguridad.
Con alrededor de 100 incidentes serios de seguridad reportados diariamente en Inglaterra – una tasa que no cambiado en las últimas dos décadas – otros países no están mejores.
Necesitamos encontrar formas más efectivas para garantizar la seguridad del paciente.
Los análisis de incidentes de seguridad han revelado una amplia gama de factores que contribuyen y a menudo personal inocente hereda los problemas existentes del sistema.
Por ejemplo, la escasez de personal puede significar mayores cargas de trabajo, lo que aumenta la rotación y crea una mayor escasez de personal.
Intentar aliviar esta situación mediante la contratación de personal temporario causa falta de familiaridad con el lugar de trabajo, lo que provoca más interrupciones e, irónicamente, un aumento de la carga de trabajo.
Esto es un terreno fértil para que ocurran errores. Por lo tanto, el pensamiento sistémico alienta la idea de que los incidentes NO suelen ser causados por una sola decisión o acción catastrófica, sino debido interacciones dinámicas entre personas, tareas, tecnología y condiciones de trabajo, incluyendo la gestión, la regulación y la política laboral,
que típicamente escapan al análisis.
Tomemos como ejemplo un error de medicación Una sobre prescripción de insulina La enfermera especializada en diabetes escribe la dosis recomendada en un formulario de evaluación.
Un ocupado médico lo malinterpreta y prescribe 100 unidades en lugar de 10.
¿El resultado?
El paciente es dado de alta, pero poco después es readmitido en el Departamento de Emergencias que de por sí ya está sobrecargado de trabajo.
Un análisis simple de causa raíz identifica el error y puede recomendar el reentrenamiento y la reflexión personal por parte de los involucrados.
Sin duda, la próxima vez, el médico tendrá más cuidado.
Pero, ¿y si la próxima vez es un médico diferente?
El mismo incidente podría suceder nuevamente.
El pensamiento sistémico nos permite explorar las interacciones dinámicas subyacentes entre personas, tecnologías y políticas dentro y a través de los niveles de los sistemas completos.
Destaca un claro mecanismo de retroalimentación para el equipo de compras, organismos reguladores y fabricantes con respecto al riesgo de confusión con el nombre del medicamento y solicita la mejora.
Otorga la responsabilidad de prescribir a la enfermera especialista para que el número de interacciones potencialmente inseguras puedan reducirse, sin importar si existe un cambio de personal.
Identifica la necesidad de un nivel adecuado de carga de trabajo y recomienda al personal que recuerde su responsabilidad de expresar sus dudas e inquietudes.
Debido a que el pensamiento sistémico considera más que las acciones individuales de las personas ofrece una oportunidad para el aprendizaje a largo plazo y el cambio duradero.
Y si la acción inmediata no es posible,
las organizaciones, al menos, acumulan una base de evidencia para futuros cambios.
Al permitir a las personas expresarse y utilizar sus habilidades y conocimientos para actuar de manera segura, El pensamiento sistémico pone énfasis en el personal como un recurso para la seguridad en lugar de una fuente potencial de problemas.
Si Usted busca formas efectivas y sostenibles de evitar daños al paciente debido a incidentes, adopte y promueva el pensamiento sistémico en sus investigaciones.
Para más información, por favor visite nuestro sitio web.
Chinese
系统思维: 如何全面分析医疗事故?
公共医疗的质量与安全性一直倍受关注
然而医疗体系正面临巨大压力
预算不足、成本上涨、医护人员短缺、需求增长
以及新技术应用
都在助长医疗事故的发生
在英国，大约每天有100起严重医疗事故见诸报告
并且在过去20年间没有明显改善，其他国家也面临类似问题
因此我们需要找到更有效的方法来保证患者的安全
针对医疗事故的分析工作揭示出了
大量的不利影响因素
同时发现并无过错的医护人员却经常要承担系统问题的责任
例如，医护人员短缺意味着更高的工作强度
这将促使人员流失，继而导致更加严重的人员短缺
如果试图通过雇佣临时工来缓解问题
由于临时工并不熟悉工作环境
反而会为工作带来更多阻碍
最终导致工作强度不降反升
而此类医疗环境正是事故多发的温床
因此，系统思维的主要观点是
事故起因往往并不是单一的错误决策或者错误行为
而是人员、任务、技术和工作环境之间的动态交互过程
这些交互过程包括管理、法规和政策
往往由于疏于分析而导致事故发生
我们用一起错误用药的事故来举例
胰岛素用药过量
糖尿病专科护士在评估表格中写下推荐用药剂量
但是一位忙碌的处方医生误读了数字
并错误的用药100单位而不是10单位
结果呢？
这名患者在出院后不久便再次入院
进一步为本已不堪重负的急诊科增加负担
运用根源分析方法可以识别出错误行为
继而对相关人员提出再培训和反思总结的建议
当然，下一次，医生将会更加注意这些问题
但是下一次如果更换了一位医生呢？
同样的事故可能再次发生
我们运用系统思维可以探索
整个系统中跨越各个层次的
人员、技术和政策之间的
潜在动态交互过程
系统思维可以建立清晰的反馈机制
用来提醒采购团队、管理部门和生产商
某类药品名称可能引起的数字混淆风险
并要求改进
同时建议专科护士担负起处方职责
这样可以有效减少潜在的不安全交互行为
也不必担心人员更替带来的麻烦
系统思维还可以确定合理的工作量水平
继而建议医护人员在恪尽职守的同时，主动提出相关疑问和要求
由于系统思维并不依赖于对个体成员的单一活动进行分析
因此有利于相关人员长期学习并持续更新观念
并且，如果无法立刻采取行动
管理者至少可以为应对未来的变化积累实证基础
系统思维鼓励人们表达观点并运用他们的技能和知识来促进系统安全
强调医护人员应是一项促进安全的重要资源
而不是问题的潜在来源
如果你正在寻找有效并可持续的方法
来预防医疗事故中的医患伤害
那么在事故调查程序中引入系统思维将是明智的
欲了解更多信息，请访问我们的网站
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