Risk Management: AcciMap

Safety and adverse event process and human factors is a process that can be utilisised to learn from. I am sure most people in healthcare have experienced the ‘no blame’ culture approach to blaming said individual.

Proactive Risk Management:

So an alternative approach to the traditional to root cause analysis is a systems based analysis called AcciMap. Inspired by Reason’s Swiss Cheese model and developed by Jens Rasmussen

AcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto six levels:

  1. Government policy and budgeting
  2. Regulatory bodies and associations
  3. Local health economy planning and budgeting (including hospital management)
  4. Technical and operational management
  5. Events, processes and conditions
  6. Outcomes


  • Aviation
  • Defence
  • Oil and Gas Industry
  • Public Health
  • Rail Transport

Case Analysis:

Canham, A., Jun, G. T., Waterson, P., & Khalid, S. (2018). Integrating systemic accident analysis into patient safety incident investigation practices. Applied Ergonomics72, 1-9.

Igene, O. O., Johnson, C. W., & Long, J. (2021). An evaluation of the formalised AcciMap approach for accident analysis in healthcareCognition, Technology & Work, 1-21.

Salmon, P. M., Cornelissen, M., & Trotter, M. J. (2012). Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMPSafety Science50(4), 1158-1170.

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Human Centred Design