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Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations

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dc.contributor.authorBowditch, L.
dc.contributor.authorMolloy, C.
dc.contributor.authorKing, B.
dc.contributor.authorAbedi, M.
dc.contributor.authorJackson, S.
dc.contributor.authorBierbaum, M.
dc.contributor.authorYu, Y.
dc.contributor.authorRaggett, L.
dc.contributor.authorSalmon, P.
dc.contributor.authorBraithwaite, J.
dc.contributor.authorWestbrook, J.I.
dc.contributor.authorClay Williams, R.
dc.contributor.authorLingam, R.
dc.contributor.authorMiddleton, S.
dc.contributor.authorMagrabi, F.
dc.contributor.authorMumford, V.
dc.contributor.authorHibbert, P.
dc.date.issued2025
dc.description.abstractBackground: Globally, up to 17% of hospitalised people suffer a patient safety incident. Learning from adverse events through patient safety investigation is critical to prevention; however, their utility is still questioned. Two key investigation outputs include identifying contributing factors (CFs) and proposing recommendations to prevent future occurrences. Criticisms of current methods include incomplete analysis of CFs and weak incident prevention strategies. A proposed solution is systems thinking analysis, which recognises healthcare complexity. However, it is not clear whether such methods are being applied in practice. Objective: This study aimed to assess current use of systems thinking-based strategies by examining a set of Australian patient safety incident investigations. Methods: Investigations (n=300) from 56 different Australian health services were deductively analysed. Identified CFs were classified by healthcare system level using a framework combining Systems Engineering Initiative for Patient Safety (SEIPS) principles and AcciMap’s hierarchical structure. Recommendation sustainability and effectiveness were classified as weak, medium or strong using US Department of Veteran Affairs’ criteria. Results: 51% of incidents were issues with clinical processes and procedures. The investigations identified CFs that disproportionally focused on the people involved in those processes (n=677, 47%) rather than other system levels and as a consequence, most recommendations were of medium (n=665, 51%) and weak (n=560, 43%) strength. Notably, 10% of investigations lacked any CFs or recommendations. Conclusion: The focus on individual actions highlighted that simple linear thinking persists in patient safety incident investigations. This study proposes five key areas of effective incident analysis and investigation: a sociotechnical focus; improved data collection techniques; investigative independence; the professionalisation of investigators; and the aggregation of data. Learning from incidents is key to maximising their preventative effectiveness, especially in an increasingly complex healthcare system.
dc.identifier.citationBMJ Quality and Safety, online, 2025; online:1-13
dc.identifier.doi10.1136/bmjqs-2025-019063
dc.identifier.issn2044-5415
dc.identifier.issn2044-5423
dc.identifier.orcidHibbert, P. [0000-0001-7865-343X]
dc.identifier.urihttps://hdl.handle.net/11541.2/44542
dc.language.isoen
dc.publisherBMJ Group
dc.rightsCopyright 2025 The Authors. (https://creativecommons.org/licenses/by/4.0/) Access Condition Notes: This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made.
dc.source.urihttps://doi.org/10.1136/bmjqs-2025-019063
dc.subjectpatient safety
dc.subjectincident reporting
dc.subjecthuman factors
dc.subjectsignificant event analysis
dc.subjectcritical incident review
dc.titleDo patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations
dc.typeJournal article
pubs.publication-statusPublished
ror.mmsid9917071326001831

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