Systemic Accident Analysis Methods What are they? How feasible in healthcare?

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1 Systemic Accident Analysis Methods What are they? How feasible in healthcare? Gyuchan Thomas Jun and Patrick Waterson Human Factors and Complex Systems Research Group Loughborough Design School, Loughborough University

2 Incident investigation Complex process Time available for investigation Availability of people involved in accidents Financial resource Competences needed for design Pressure from management Approval mechanism Stop-rule Need for Systemic Models and Approaches

3 RCA is fine? RCA suffers more from an implementation problem (and potentially a name problem) than being fundamentally flawed RCA done well is a proper systems-based investigation

4 Norman Door Affordance: It is not you. Bad doors are everywhere b8wgi Action possibilities that are readily perceivable by an actor

5 RCA 5 Whys Fishbone Diagram Affordance: Thinking possibilities that are readily perceivable by an investigator It is not you, but bad method?

6 Constellation Diagram To overcome limitations You can find the diagram on Page 44 in Canadian Incident Analysis Framework of fishbone and tree diagrams Define inter-relationships between and among potential contributing factors

7 Structure 1. Animation 2. AcciMap 1. Present (me) 2. Evaluate (you) Break 10-15min 3. Discuss (together) 3. Hierarchical Control Structure Diagram 4. Causal Loop Diagram

8 Background Evidence into Practice grant by the Health Foundation To bridge the gap from academic research findings, to actionable information for people practising in the field YouTube: Vimeo:

9 Medication Safety Group Pharmacies at UHL Leicestershire Partnership NHS Trust Making Process

10 Our Understanding has moved on Complex Linear Swiss Cheese model London Protocol Complex Non-linear Safety migration Emergent properties Safety II

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12 Accident causation models Healthcare incidents result from 1. Multiple contributing factors, NOT just a Single catastrophic decision or action 2. Lack of vertical integration across levels, NOT just deficiencies at any one level alone 3. Gradual degradation of work practices, NOT Static work practices 4. Emergent properties arising from Non-linear interactions, NOT necessarily Mechanistic properties from Linear interactions 5. Normal work of actors NOT necessarily from errors, failures or violations

13 Your Responses? What message(s) did you take away from the animation? What actions did you take, if any, share it, visit the website or use it? What challenges do you find in taking message(s) or action(s)?

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15 Consent Evaluate (page 1-3) Discuss What message(s) do you take away from the animation? What actions did you take, if any, e.g. share it, visit the website or use it? What challenges do you find in taking message(s) and action(s)?

16 System Diagrams AcciMap Hierarchical Safety Control Structure Diagram Causal Loop Diagram (Influence Diagram)

17 AcciMap Insulin over-prescription

18 Background Graphically represent the system-wide Events and Conditions that interacted to result in accidents Government Laws Safety review Regulators Regulations Incident reports Company Company policy Operations review Management Plans Logs and work reports Staff Action Observations, data Work and hazard process Rasmussen s Systemic Accident Model (1997)

19 AcciMap Modelling Events and Conditions

20 MS Herald of Free Enterprise at Zeebrugge in 1987 Commercial pressures Performance prioritized over safety Disregard of safety procedures Poor safety culture Poor design of vessel Ineffective supervision Communication failures Loading ramp was too low No visual or audible indicators No emergency procedures in place Situational violation - Rules had become difficult to follow No view of doors from bridge Shift handover from assistant officer to officer Doors left open Water enters car deck Water enters electrical systems Herald sinks Rasmussen and Svedung (2000)

21 Outdoor incidents contributing factors classification Injury causing outdoor incidents (n=363) PreventiMap Dallat, C.E., Salmon, P.M., Goode, N., Taylor, N., Lenn, M.G., Finch, C.F., Applied Ergonomics, Rasmussen s legacy in the great outdoors : A new incident reporting and learning system for led outdoor activities 59,

22 Evaluation Your perception Easily understandable? Useful in analysing systemic causes of an incident? identifying system-based recommendations? Practical? Reliable? Intend to use?

23 Evaluate (page 4) Discuss

24 System Diagrams AcciMap Hierarchical Safety Control Structure Diagram Causal Loop Diagram (Influence Diagram)

25 Background Accidents are more than a chain of events Control Actions Controller Mental Model Controlled Process Feedback Treat accidents as a control problem Prevent accidents by enforcing constraints on component, behaviour and interactions

26 Generic Safety Control Structure Legislation Policy Regulations Standards Certification Legal penalties Operation policy Standards Resources Operating Process SYSTEM OPERATION Government Regulatory Agencies Hospital Management Operations Management Human Controller(s) Process Model Reports Lobbying Accidents Accidents and incidents Operations reports Maintenance reports Whistleblowers Operations reports Audit reports Problem reports Goal is to identify the flaws in the system control structure that contributed to the Incident to determine how to redesign the safety control structure to be more effective Physical Process Feedback (adapted from Leveson, 2011)

27 Healthcare SYSTEM DEVELOPMENT Legislation Policy Government Reports Lobbying Accidents SYSTEM OPERATION Legislation Policy Government Reports Lobbying Accidents Regulations Standards Certification Legal penalties Purchasing policy Recruitment policy Training policy Information policy Regulatory Agencies Hospital Management Change Management Certification info. Change reports Whistleblowers Accidents and incidents Status reports Risk assessment Incident reports Regulations Standards Certification Legal penalties Operation policy Standards Resources Regulatory Agencies Hospital Management Operations Management Accidents and incidents Operations reports Maintenance reports Whistleblowers Operations reports Safety Standards Safety constraints Standards Test requirements Design, Documentation Implementation and assurance Hazard analyses Audit reports Problem reports Test report Review results Revised operating procedures Maintenance Problem reports Change requests Work instructions Operating Process Control actions Human Controller(s) Process Model Physical Process Audit reports Problem reports Feedback (Adapted from Leveson, 2004)

28 Inadequate Control Actions 1. Not Given 2. Unsafe 3. Given too early, too late 4. Stop too soon or applied too long

29 Control Map - Insulin over-prescription

30 Strengthening a Control Action Ineffective Control Actions Healthcare professionals Patient Mental Model Feedback - Improve patient engagement and relational aspects - How to better design system and services or better equip staff? - Why poor engagement?

31 Evaluation Your perception Easily understandable? Useful in analysing systemic causes of an incident? identifying system-based recommendations? Practical? Reliable? Intend to use?

32 Evaluate (page 5) Discuss

33 System Diagrams AcciMap Hierarchical Safety Control Structure Diagram Causal Loop Diagram (Influence Diagram)

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35 Causal Loop Diagram Feedback structure of systems between nodes (factors) and + + Births Population Deaths + - arrows (negative and positive influences). Understand the nonlinear behaviour of complex systems Reinforcing loop Balancing loop over time using feedback loops, and time delays

36 Negatively-Reinforcing Loops + Staff shortage + + Temporary workers Reinforcing loop High staff turn-over + High workload + + Likelihood of errors Reinforcing loop + More interruptions

37 Dispensing Errors in Hospital Pharmacy Number of staff + - Backlog Workload Balancing loop Reinforcing loop Amount of Rework Time to self-check for errors + - Dispensing errors

38 Evaluation Your perception Easily understandable? Useful in analysing systemic causes of an incident? identifying system-based recommendations? Practical? Reliable? Intend to use?

39 Evaluate (page 6) Discuss

40 Safety I vs Safety II How things go wrong How things go right Mental health patients with suicide risk Incident Analysis Patient Engagement Suicide Risk Assessment Communication and Coordination Staff interview Peer support (formal and informal)

41 What is Next? Tool development for practice? Better understand your investigation practices? Hopefully work together

42 Jay Forrester Hope for the coming century is to develop a sufficiently large percentage of population that have true insight in the nature of complex systems which they live.

43 For more information Visit a project website: Contact Thomas Jun g.jun@lboro.ac.uk