Loughborough University
JERG-D-17-00621R1-accepted.pdf (1010.58 kB)
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Integrating systemic accident analysis into patient safety incident investigation practices

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journal contribution
posted on 2018-05-29, 12:33 authored by Nye Canham, Gyuchan Thomas JunGyuchan Thomas Jun, Patrick WatersonPatrick Waterson, Suzanne Khalid
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.



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Applied Ergonomics




CANHAM, A. ... et al, 2018. Integrating systemic accident analysis into patient safety incident investigation practices. Applied Ergonomics, 72, pp.1-9.


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This work is made available according to the conditions of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) licence. Full details of this licence are available at: https://creativecommons.org/licenses/by-nc-nd/4.0/

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This paper was accepted for publication in the journal Applied Ergonomics and the definitive published version is available at https://doi.org/10.1016/j.apergo.2018.04.012




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