Weak signals in healthcare: A case study on community-based patient discharge

To adjust performance to ensure the success of a task and prevent error, it is necessary to anticipate, identify and respond to variations in the work system. The objectives of this study were to develop a framework for the analysis of signals, which provide an indication of variations in the system, in the healthcare environment and qualitatively investigate signals in the context of community-based patient discharge. In addition to the signals, both traditional (Safety-I) and proactive safety (SafetyII) elements were investigated with six expert groups, from the field of community-based patient discharge. The signals identified and the safety elements were analysed using the SEIPS 2.0 model. The sources of the signals were identified as originating from work system elements. The proposed framework and method provide a preliminary basis for the investigation of signals and assists in highlighting the role that these can play in safety behaviour.