Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events

Copyright © 2018 Society for Simulation in Healthcare. One of the most fundamental principles of patient safety is to investigate and learn from the past in order to improve the future. However, healthcare organizations can find it challenging to develop the robust organizational processes and work practices that are needed to rigorously investigate and learn from safety incidents. Key challenges include difficulties developing specialist knowledge and expertise, understanding complex incidents, coordinating collaborative action, and positively changing practice. These are the types of challenges that simulation is commonly used to address. As such, this article proposes that there are considerable opportunities to integrate simulation more deeply and systematically into routine efforts to investigate and learn from safety incidents. This article explores how this might be performed by defining five key areas where simulation could be productively integrated throughout the investigation and learning process, drawing on examples of current practice and analogous applications in healthcare and other industries

Delivering high reliability in maternity care: In situ simulation as a source of organisational resilience

© 2016 Elsevier Ltd The fields of resilience engineering and high reliability organising both seek to explain the key sources and characteristics of safety in organisations that operate under conditions of considerable complexity, variability and surprise. A key focus in both of these fields is explaining how organisations can use adaptive and flexible work processes to deliver safe and reliable services, and how organisations can draw on past events and new experiences to increase their capacity to handle disruptive and unexpected events. To explore these issues, this paper develops an analysis of the routine use of on-site or ‘in situ’ simulation of emergency events as part of a systematic approach to safety management in the healthcare setting of maternity care. This analysis identifies three core organising processes through which in situ simulation can act as a source of organisational safety: relational rehearsal, system structuring and practice elaboration. We use this analysis to examine the opportunities that exist to develop more integrated explanatory accounts of high reliability organising and resilience engineering, particularly exploring the tensions between organisational stability and change, proactive and reactive modes of organising, and organisational strength and weakness

Emergency Manuals: How Quality Improvement and Implementation Science Can Enable Better Perioperative Management During Crises

© 2017 Sara N. Goldhaber-Fiebert, Carl Macrae How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care

Human factors at sea: common patterns of error in groundings and collisions Human factors at sea: common patterns of error in groundings and collisions

This research aimed to identify and map the common patterns of human and organizational causes underlying two types of marine accident: groundings and collisions. Generalising patterns of causality from relatively unique and individual accident events required a structured and exploratory analytical approach. Two complementary human factor analysis tools were employed to analyse a set of 30 detailed marine accident reports produced by the Australian Transport Safety Bureau. Common patterns of causality were identified for both groundings and collisions. Groundings commonly resulted from a failure to adequately plan a passage, coupled with either a problem locating the vessel, or communication problems on the bridge. Collisions often involved a fishing vessel and a bulk carrier or cargo vessel, and commonly resulted from both a problem identifying the existence or speed of the other vessel and, again, an inadequate planning process. Generalising these common causal patterns from a number of accidents identifies a range of points at which crews, managers and policymakers can intervene to forestall the development of these accidents. The method developed here may also be productively extended and applied to other accident types and used as an ongoing risk management tool

Learning from the failure of autonomous and intelligent systems: accidents, safety and sociotechnical sources of risk

Efforts to develop autonomous and intelligent systems (AIS) have exploded across a range of settings in recent years, from self-driving cars to medical diagnostic chatbots. These have the potential to bring enormous benefits to society but also have the potential to introduce new—or amplify existing—risks. As these emerging technologies become more widespread, one of the most critical risk management challenges is to ensure that failures of AIS can be rigorously analyzed and understood so that the safety of these systems can be effectively governed and improved. AIS are necessarily developed and deployed within complex human, social, and organizational systems, but to date there has been little systematic examination of the sociotechnical sources of risk and failure in AIS. Accordingly, this article develops a conceptual framework that characterizes key sociotechnical sources of risk in AIS by reanalyzing one of the most publicly reported failures to date: the 2018 fatal crash of Uber's self-driving car. Publicly available investigative reports were systematically analyzed using constant comparative analysis to identify key sources and patterns of sociotechnical risk. Five fundamental domains of sociotechnical risk were conceptualized—structural, organizational, technological, epistemic, and cultural—each indicated by particular patterns of sociotechnical failure. The resulting SOTEC framework of sociotechnical risk in AIS extends existing theories of risk in complex systems and highlights important practical and theoretical implications for managing risk and developing infrastructures of learning in AIS

Safety analysis over time: seven major changes to adverse event investigation

© 2017 The Author(s).BackgroundEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.Main textThe primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects.We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.ConclusionsPrevious methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches