The NHS should alter the way it investigates cases of serious failures involving patient care

Replacing the method by which serious clinic incidents, such as over-prescribing insulin, are investigated could reduce the chances of repeat mistakes being made.

This is the advice from Loughborough University’s Dr Thomas Jun, who is working with hospitals to change the way serious incident investigations into medical errors, such as dispensing errors and procedural faults, are carried out.

The current approach, he says, is ineffective because it often leads to apportioning blame, rather than understanding the often-complicated and multidimensional factors contributing to the medical error.

Dr Jun said that the NHS’s standard approach, known as root cause analysis (RCA), has done little to reduce the hundreds of cases of serious incidents which happen across the health service every day.

Now, Dr Jun and Dr Patrick Waterson, of Loughborough’s Design School, have created a three-minute educational animation to raise awareness of ‘systems thinking’ – a holistic investigative approach which factors-in the broad range of factors which leads to safety incidents.

The pair have also launched the Systems Thinking Lab – an online resource which explains the concepts, principles and examples of three different systemic accident analysis applications.

Dr Jun said: “We understand that the quality and effectiveness of incident investigation outcomes in local healthcare are much more than simple methodological issue – for example, time constraints, expertise, politics and bias.

“However, we believe, as a couple of recent articles published in BMJ Quality and Safety has demonstrated, that the RCA approach tends to promote a flawed reductionist view, which can easily create blame culture and resultant remedial actions focusing only on staff retraining.”

Systems thinking, on the other hand, takes the view that incidents are not usually caused by a single catastrophic decision or action.

It focuses on the interactions between people, tasks, technology and working conditions, as well as management, regulation and policy.

The systemic analysis methods are already used in other high-risk industries such as aviation, rail, and oil and gas.

Dr Jun said: “The need for a systems thinking approach in healthcare has been raised for more than 20 years, but without an understanding of what does it look like and how can it be done.

“The recent launch of the Healthcare Safety Investigation Branch (HSIB) and the establishment of the draft Health Services Safety Investigation Bill are very promising, but there is an urgent need to develop the systems thinking capacity in local-level patient safety incident investigation teams.”

The animation, released last month, has been viewed more than 3,200 times and has been used for RCA training and medical education in the UK and beyond.

“It has already sparked many interesting conversations with policy makers, healthcare managers, incident investigators, researchers and educators,” said Dr Jun.

He is now looking for ways to spread the message further and running a series of workshops and meetings with important healthcare stakeholders to discuss how to put into practice the important message in the animation.

“Through these engagements, we hope to contribute to making positive change in incident investigation training and policy in healthcare.”

The £50,000 project was carried out in partnership with Leicestershire Improvement, Innovation and Patient Safety Unit and Cognitive Media, and was sponsored by the Health Foundation.


Notes for editors

Press release reference number: 17/150

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