A systems ergonomics analysis of the Maidstone and Tunbridge Wells infection outbreaks

This paper describes a systems ergonomics analysis of the recent outbreaks of Clostridium difficile which occurred over the period 2005-07 within the UK Maidstone and Tunbridge Wells NHS Trust. The analysis used documents related to the outbreak, alongside the construction of a system model in order to probe deeper into the nature of contributory factors within the Trust. The findings from the analysis demonstrate the value of looking further at cross-level and whole-system aspects of infection outbreaks. In particular there is a need for further study of the causal relationships that exist between hospital management and clinical management levels within the system. Finally, the paper discusses ways forward and strategies that could adopted in order to limit the outbreak of hospital-related infections and shape future research

Taking stock of the systems approach to patient safety

The application of concepts, theories and methods from systems ergonomics to the domain of patient safety has proved to be an expanding area of research and application in the last 15 years. This paper describes a review of the approach which aimed to identify: the main issues that have been researched; the types of methods of investigation adopted by researchers; the extent to which different system levels are covered; and, the types of medical domain in which work has gone on in the last few years. A total of 360 papers were selected for a detailed review. Approximately 16% of these focused on human error, followed by safety/error frameworks (13%), incident reporting (12%) and perceptions of safety/risk (9%). Most studies have addressed system concerns at the level of the individual (27%). The most frequent methodology used within research adopting the approach are case studies (33%). The findings from the review are discussed within the context of previous evaluations and criticisms of the systems approach and patient safety

Ergonomics and infection outbreaks

Ergonomics and infection outbreak

System analysis for infection control in acute hospitals

This paper makes the case for applying a systems perspective to the analysis of hospital-based infection outbreaks. Most of the research that has been conducted on behavioural aspects of infection control has focused on explanations at an individual level of analysis (e.g., interventions to improve hand washing). The infections outbreaks at the Maidstone and Tunbridge Wells NHS Trust are analysed in detail using an established framework for risk management. The paper further outlines the human and organisational issues raised by the analysis and provides a means through which these aspects of infection can be highlighted as part of a future research agenda within systems ergonomics

A critical review of the systems approach within patient safety research

The application of concepts, theories and methods from systems ergonomics within patient safety has proved to be an expanding area of research and application in the last decade. This paper aims to take a step back and examine what types of research have been conducted so far and use the results to suggest new ways forward. An analysis of a selection of the patient safety literature suggests that research has so far focused on human error, frameworks for safety and risk, and incident reporting. The majority of studies have addressed system concerns at an individual level of analysis with only a few analysing systems across multiple system boundaries. Based on the findings it is argued that future research needs to move away from a concentration on errors and towards an examination of the connections between systems levels. Examples of how this could be achieved are described in the paper

Infection outbreaks in acute hospitals: a systems approach

This paper puts forward the case for applying a systems approach to the analysis of hospital-based infection outbreaks. A major advantage of the systems approach is that it affords insights into how actions or occurrences at one system level (e.g. individual error) collectively interact with team (e.g. leadership style) and organisational (e.g. safety culture) levels of analysis. Most of the research concerned with behavioural aspects of infection control has focused on a single level of analysis (e.g. interventions to improve hand washing). The infection outbreaks at the Maidstone and Tunbridge Wells NHS Trust are used as a case study in order to demonstrate the usefulness of the systems approach. The paper further outlines the human and organisational issues raised by the analysis and provides a means through which these aspects of infection can be highlighted as part of a future research agenda

Sacrifices in the name of science

Sacrifices in the name of scienc

Systemic accident analysis: examining the gap between research and practice

The systems approach is arguably the dominant concept within accident analysis research. Viewing accidents as a result of uncontrolled system interactions, it forms the theoretical basis of various systemic accident analysis (SAA) models and methods. Despite the proposed benefits of SAA, such as an improved description of accident causation, evidence within the scientific literature suggests that these techniques are not being used in practice and that a research–practice gap exists. The aim of this study was to explore the issues stemming from research and practice which could hinder the awareness, adoption and usage of SAA. To achieve this, semi-structured interviews were conducted with 42 safety experts from ten countries and a variety of industries, including rail, aviation and maritime. This study suggests that the research–practice gap should be closed and efforts to bridge the gap should focus on ensuring that systemic methods meet the needs of practitioners and improving the communication of SAA research

Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models

The Swiss Cheese Model (SCM) is the most popular accident causation model and is widely used throughout various industries. A debate exists in the research literature over whether the SCM remains a viable tool for accident analysis. Critics of the model suggest that it provides a sequential, oversimplified view of accidents. Conversely, proponents suggest that it embodies the concepts of systems theory, as per the contemporary systemic analysis techniques. The aim of this paper was to consider whether the SCM can provide a systems thinking approach and remain a viable option for accident analysis. To achieve this, the train derailment at Grayrigg was analysed with an SCM-based model (the ATSB accident investigation model) and two systemic accident analysis methods (AcciMap and STAMP). The analysis outputs and usage of the techniques were compared. The findings of the study showed that each model applied the systems thinking approach. However, the ATSB model and AcciMap graphically presented their findings in a more succinct manner, whereas STAMP more clearly embodied the concepts of systems theory. The study suggests that, whilst the selection of an analysis method is subject to trade-offs that practitioners and researchers must make, the SCM remains a viable model for accident analysis

'When food kills': a socio-technical systems analysis of the UK Pennington 1996 and 2005 E. coli O157 Outbreak Reports

In 1996 and 2005, two of the largest E. coli O157 outbreaks occurred in the UK. Many people were infected after consuming meat resulting in a number of deaths. In the present study we applied a systems approach to both the outbreak reports to analyse and compare the accidents. Using the Accimap method of systems analysis, this study investigates the human errors and organisational issues involved in the outbreaks and why accidents such as these occur in the food production domain. The systems analysis carried out in this study on the two outbreaks indicates that there are both common as well as unique factors associated with the two outbreaks. The study concludes that it is necessary to address food safety from a systemic point of view and identify and solve the various problems that could arise in the system, in the pre-incubation period before the outbreak actually occurs