Adopting systems models for multiple incident analysis: utility and usability.

Area of Science:

• Human Factors and Ergonomics (HF/E)
• Patient Safety Science
• Systems Engineering

Background:

• Current patient safety incident analysis relies on inductive thematic analysis and barrier analysis for interventions.
• No formal systems models have been evaluated for improving incident exploration and developing remedial actions in England's national patient safety team.
• This study evaluates the adoptability of two HF/E system models for enhancing patient safety processes.

Purpose of the Study:

• To evaluate the utility and usability of AcciMap and SEIPS models for England's national patient safety team.
• To assess the potential of these models in improving the analysis of multiple incident reports.
• To determine the models' effectiveness in developing remedial actions for National Patient Safety Alerts.

Main Methods:

• AcciMap and SEIPS models were applied to analyze two sets of patient safety incidents.
• Analysis involved a first author assessment and a collective evaluation by patient safety team members.
• Participants received training and attended a workshop, followed by individual interviews to assess perceived utility and usability.

Main Results:

• Patient safety teams recognized the high utility of both models as frameworks for systematic issue analysis.
• AcciMap provided a comprehensive visual overview but was perceived as chaotic by some.
• SEIPS was found easier to understand due to its familiar structure but its non-hierarchical format was seen as less useful.

Conclusions:

• Both AcciMap and SEIPS models offer significant utility for patient safety analysis, despite usability concerns.
• Complexity and the need for further training/coaching were identified as barriers to daily practice adoption.
• Bridging the gap between HF/E and patient safety practitioners requires enhanced education, coaching, and mentoring.