Stopping incidents in their tracks: identifying weak signals for error prevention in healthcare
conference contributionposted on 26.01.2017, 17:02 by Evi Carman, Michael FrayMichael Fray, Patrick WatersonPatrick Waterson
In order to adjust performance to ensure the success of a task and prevent error, it is necessary to anticipate, identify and respond to signals indicating changes in the system. The objectives of this study were to investigate weak signals within two different healthcare case studies by identifying key elements and behaviours of these tasks. This study investigated both Safety-I and Safety-II elements with four expert groups, two from the field of patient handling and two from the field of patient discharge. The Safety-I and Safety-II elements explored included potential errors, influencing factors, weak signals and learning opportunities arising from the investigated situations. The errors identified by the focus groups were related to skill, knowledge, inappropriate equipment, equipment misuse, lack of communication, missing or incomplete information, incorrect technique, and preconditions not being fulfilled. The influencing factors identified by the two case studies included patient-related factors, time and space-related factors as well as organizational and managerial factors such as available resources and safety culture. The weak signals identified in both case studies were analysed using the SEIPS 2.0 model. The sources of the signals were identified as originating from the work system elements “person”, “tasks”, “organization” and “internal environment”. The manifestation forms of the weak signals included the different sensory signals as well as the experience of intuition or “hunches”. Potential learning opportunities to improve signal recognition were identified and included the need for reflection and empowerment, continuous assessment and the sharing of information between the involved systems. The proposed framework and method provide a preliminary basis for the investigation of weak signals and assists in highlighting the role that the weak signals can play in safety behaviour.