{
  "abstract": "Background Globally, up to 17% of hospitalised people suffer a patient safety incident. Learning from adverse events through patient safety investigation is critical to prevention; however, their utility is still questioned. Two key investigation outputs include identifying contributing factors (CFs) and proposing recommendations to prevent future occurrences. Criticisms of current methods include incomplete analysis of CFs and weak incident prevention strategies. A proposed solution is systems thinking analysis, which recognises healthcare complexity. However, it is not clear whether such methods are being applied in practice.Objective This study aimed to assess current use of systems thinking-based strategies by examining a set of Australian patient safety incident investigations.Methods Investigations (n=300) from 56 different Australian health services were deductively analysed. Identified CFs were classified by healthcare system level using a framework combining Systems Engineering Initiative for Patient Safety (SEIPS) principles and AcciMap’s hierarchical structure. Recommendation sustainability and effectiveness were classified as weak, medium or strong using US Department of Veteran Affairs’ criteria.Results 51% of incidents were issues with clinical processes and procedures. The investigations identified CFs that disproportionally focused on the people involved in those processes (n=677, 47%) rather than other system levels and as a consequence, most recommendations were of medium (n=665, 51%) and weak (n=560, 43%) strength. Notably, 10% of investigations lacked any CFs or recommendations.Conclusion The focus on individual actions highlighted that simple linear thinking persists in patient safety incident investigations. This study proposes five key areas of effective incident analysis and investigation: a sociotechnical focus; improved data collection techniques; investigative independence; the professionalisation of investigators; and the aggregation of data. Learning from incidents is key to maximising their preventative effectiveness, especially in an increasingly complex healthcare system.",
  "authors": [
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Lorelle Bowditch"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia",
        "IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia"
      ],
      "name": "Charlotte Molloy"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia",
        "University of the Sunshine Coast Centre for Human Factors and Sociotechnical Systems, Sippy Downs, Queensland, Australia"
      ],
      "name": "Brandon King"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia",
        "University of the Sunshine Coast Centre for Human Factors and Sociotechnical Systems, Sippy Downs, Queensland, Australia"
      ],
      "name": "Masoumeh Abedi"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia",
        "University of the Sunshine Coast Centre for Human Factors and Sociotechnical Systems, Sippy Downs, Queensland, Australia"
      ],
      "name": "Samantha Jackson"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Mia Bierbaum"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Yinghua Yu"
    },
    {
      "affiliations": [
        "Nomic Research, North Turramurra, Sydney, New South Wales, Australia"
      ],
      "name": "Louise Raggett"
    },
    {
      "affiliations": [
        "University of the Sunshine Coast Centre for Human Factors and Sociotechnical Systems, Sippy Downs, Queensland, Australia"
      ],
      "name": "Paul Salmon"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Jeffrey Braithwaite"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Johanna I Westbrook"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Robyn Clay-Williams"
    },
    {
      "affiliations": [
        "UNSW School of Clinical Medicine, Sydney, New South Wales, Australia"
      ],
      "name": "Raghu Lingam"
    },
    {
      "affiliations": [
        "Nursing Research Institute - St Vincent’s Health Network Sydney & St Vincent’s Hospital, Melbourne, Victoria, Australia",
        "Australian Catholic University School of Nursing Midwifery and Paramedicine Melbourne Campus, Sydney, New South Wales, Australia"
      ],
      "name": "Sandy Middleton"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Farah Magrabi"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia"
      ],
      "name": "Virginia Mumford"
    },
    {
      "affiliations": [
        "Macquarie University Australian Institute of Health Innovation, Sydney, New South Wales, Australia",
        "IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia"
      ],
      "name": "Peter Hibbert"
    }
  ],
  "title": "Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations",
  "uid": "fe247612-769d-58ad-80a1-1b1bf13dcf31"
}