Adopting systems models for multiple incident analysis: utility and usability

This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England's national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used.

AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen. The first set was analysed by the first author and the utility and usability were reflected. The second set was analysed collectively by a purposeful sample of patient safety team members, who create the National Patient Safety Alerts from incident-level data and information. All of them attended a 30-min video-based training and a 1.5 h case-based online workshop. Post-workshop individual interviews were conducted to evaluate their perceived utility and usability of each model.

The patient safety team showed overwhelming support for the utility of the system models as a 'framework' that provides a systematic, structured way of looking at an issue and examining the causes, whilst also sharing concerns regarding their usability. AcciMap was viewed useful particularly in providing a visual comprehensive overview of the issue but considered chaotic by some participants due to many arrows between factors. SEIPS was perceived easier to understand due to the familiarity of the structure (Donbedian's model), but the non-hierarchical format of SEIPS was considered less useful.

The participants of the study agreed with the high level of utility of both models for their unique strengths, but shared some concern for the usability of them in terms of complexity and further training/coaching time would be required to adopt these models in their daily practices. It is recommended that the gap between HF/E practitioners and patient safety practitioners can be narrowed by strengthening education, and coaching and mentoring relationships between the two groups, led by the increasing number of healthcare practitioners who embrace their membership to HF/E practice.