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:
- Government policy and budgeting
- Regulatory bodies and associations
- Local health economy planning and budgeting (including hospital management)
- Technical and operational management
- Events, processes and conditions
- Oil and Gas Industry
- Public Health
- Rail Transport
Canham, A., Jun, G. T., Waterson, P., & Khalid, S. (2018). Integrating systemic accident analysis into patient safety incident investigation practices. Applied Ergonomics, 72, 1-9.
Igene, O. O., Johnson, C. W., & Long, J. (2021). An evaluation of the formalised AcciMap approach for accident analysis in healthcare. Cognition, Technology & Work, 1-21.
Salmon, P. M., Cornelissen, M., & Trotter, M. J. (2012). Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP. Safety Science, 50(4), 1158-1170.