Accelerating systems thinking in health care incident investigation

Loughborough University

This project was funded between March 2017 and March 2018.

  • Led by a team at Loughborough Design School, Loughborough University.
  • Aimed to help health care managers and clinicians improve the quality of patient safety incident reporting and promote a culture of meaningful learning.
  • Produced an animation and website to explain how to apply systems thinking to health care and develop a systemic accident analysis process.

The Human Factors and Complex Systems Research Group at Loughborough University's Design School has carried out extensive research into applying a systems approach to accident analysis across a variety of industry sectors. 

Their research in the health care environment has looked at how systemic accident analysis can be applied to patient safety incident investigation, and how contributing factors can be identified and mapped from a systems perspective.

The researchers put this evidence into practice by bringing together human factors and system safety experts, health care professionals and an animation company to develop a short hand-drawn animation using an engaging example of incorrect prescription of medication. 

The target audience was health care managers and clinicians involved in local-level health care incident investigation. The aim was to provide guidance for their overall thinking and systemic accident analysis process, leading to improvement in the quality of patient safety incident reporting and promoting a culture of meaningful learning.

The animation was widely disseminated through interest groups, social media, press releases, workshops and a project poster, attracting more than 13,000 views across 80 different countries. 

In response to user feedback, a project website was developed to provide more information on different systems thinking methods and potential applications in health care. The challenge of some NHS trusts not having access to YouTube and using PCs without sound was addressed by uploading the animation to an accessible platform (Vimeo) and including subtitles.

The project outputs are now being used as part of regular training and education programmes in at least 12 hospitals and universities worldwide.

Contact details

Dr Gyuchan Thomas Jun, Senior Lecturer, Loughborough University, g.jun@lboro.ac.uk

About this programme

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