2134/33173 Nye Canham Nye Canham Gyuchan Thomas Jun Gyuchan Thomas Jun Patrick Waterson Patrick Waterson Suzanne Khalid Suzanne Khalid Integrating systemic accident analysis into patient safety incident investigation practices Loughborough University 2018 Patient safety Incident analysis Systemic accident analysis Design Practice and Management not elsewhere classified 2018-05-29 12:33:44 Journal contribution https://repository.lboro.ac.uk/articles/journal_contribution/Integrating_systemic_accident_analysis_into_patient_safety_incident_investigation_practices/9349073 There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual–based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.