Integrating systemic accident analysis into patient safety incident investigation practices.

Aneurin Canham; Gyuchan Thomas Jun; Patrick Waterson; Suzanne Khalid

Study

Integrating systemic accident analysis into patient safety incident investigation practices.

November 21, 2018

Canham A, Jun GT, Waterson P, et al. Appl Ergon. 2018;72:1-9.

View more articles from the same authors.

This article contrasts two methods of error investigation—root cause analysis (RCA) versus Systems Theoretic Accident Modelling and Processes (STAMP) analysis—for the same adverse event. According to the authors, STAMP analysis produced more systems solutions compared to RCA, which primarily suggests individual-level remedial actions.

Available at

PubMed citation

Related Resources From the Same Author(s)

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

October 27, 2021

A critical review of the systems approach within patient safety research.

October 14, 2009

Human factors in healthcare: welcome progress, but still scratching the surface.

June 29, 2016

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.

May 5, 2021

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis.

February 7, 2024

Disclosing harmful pathology errors to patients.

January 6, 2010

Patient reports of undesirable events during hospitalization.

October 12, 2005

The use of patient digital facial images to confirm patient identity in a children's hospital's anesthesia information management system.

January 15, 2020

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

May 5, 2010

Twelve-month review of infusion pump near-miss medication and dose selection errors and user-initiated "good save" corrections: retrospective study.

November 4, 2020

Key principles in quality and safety in radiology.

May 3, 2017

Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.

August 22, 2012

Investigating the long-term consequences of adverse medical events among older adults.

June 11, 2014

Relationship between nurse burnout, patient and organizational outcomes: systematic review.

August 18, 2021

Detection rates of mild cognitive impairment in primary care for the United States Medicare population.

November 15, 2023

Rate of undesirable events at beginning of academic year: retrospective cohort study.

October 28, 2009

Prevalence and nature of adverse medical device events in hospitalized children.

June 26, 2013

Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.

September 25, 2019

Patient, physician, medical assistant, and office visit factors associated with medication list agreement.

March 9, 2016

Evaluation of drug utilization and prescribing errors in infants: a primary care prescription-based study.

June 13, 2007

The doctor's new dilemma.

February 24, 2016

Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law.

February 20, 2019

Patient safety: it's not just carefulness, it's a culture.

March 6, 2005

Rates of safety incident reporting in MRI in a large academic medical center.

November 18, 2015

Implementation and impact of a rapid response team in a children's hospital.

July 11, 2007

Improving pathologists' communication skills.

September 14, 2016

Ask me if I cleaned my hands.

April 25, 2012

Medication reconciliation in a community, nonteaching hospital.

November 12, 2008

Noise: a distraction, interruption, and safety hazard.

August 22, 2007

Distractions, interruptions, and patient safety.

July 25, 2007

Hospital and procedure incidence of pediatric retained surgical items.

May 27, 2015

Electronic health record use and the quality of ambulatory care in the United States.

July 25, 2007

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences.

May 18, 2011

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

Between demarcation and discretion: the medical-administrative boundary as a locus of safety in high-volume organisational routines.

August 1, 2018

Reporting of hazards and near-misses in the ambulatory care setting.

October 19, 2011

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.

December 13, 2017

Preventing vincristine administration errors: does evidence support minibag infusions?

April 26, 2006

John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards.

March 6, 2005

Point-of-care cognitive support technology in emergency departments: a scoping review of technology acceptance by clinicians.

July 18, 2018

Quality of life after maternal near miss: a systematic review.

June 2, 2021

A simple checklist for preventing major complications associated with cesarean delivery.

January 5, 2011

Engaging the patient as observer to promote hand hygiene compliance in ambulatory care.

October 7, 2009

Incident learning in radiation oncology: a review.

August 15, 2018

Improving nursing unit teamwork.

January 4, 2006

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis.

March 16, 2022

Hospital-wide code rates and mortality before and after implementation of a rapid response team.

December 10, 2008

Characterising ICU–ward handoffs at three academic medical centres: process and perceptions.

March 20, 2019

Effects of healthcare organization actions and policies related to COVID-19 on perceived organizational support among U.S. internists: a national study.

June 1, 2022

Analysis of medical malpractice claims to improve quality of care: cautionary remarks.

June 12, 2019

Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.

December 14, 2016

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

January 25, 2012

Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

February 7, 2018

Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit.

September 16, 2020

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.

May 18, 2022

Surgical team behaviors and patient outcomes.

October 1, 2008

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.

August 8, 2012

Maintaining maternal-newborn safety during the COVID-19 pandemic.

May 26, 2021

Considering the safety and quality of artificial intelligence in health care.

September 16, 2020

An unsuspected MR projectile: a "wooden" chair with metal bracing.

May 3, 2006

Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.

March 1, 2006

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

December 5, 2018

How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.

June 13, 2012

Dynamics of dignity and safety: a discussion.

January 24, 2018

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.

May 21, 2008

Medical errors and quality of care: from control to commitment.

June 14, 2006

Interprofessional team collaboration and work environment health in 68 US intensive care units.

November 30, 2022

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

September 22, 2021

An organization-specific and modifiable inpatient safety composite measure.

May 8, 2019

The relationship between resident physician burnout and its’ effects on patient care, professionalism, and academic achievement: a review of the literature.

October 5, 2022

Telemedicine consultations and medication errors in rural emergency departments.

December 11, 2013

Frequency and types of patient-reported errors in electronic health record ambulatory care notes.

July 1, 2020

Potential biases in machine learning algorithms using electronic health record data.

August 29, 2018

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

January 8, 2014

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Has the Leapfrog Group had an impact on the health care market?

April 15, 2005

Some unintended effects of teamwork in healthcare.

March 10, 2010

Measuring the rate of manual transcription error in outpatient point-of-care testing.

March 13, 2019

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk.

January 29, 2014

Safety culture across cultures.

January 8, 2020

Transformation of health care at the front line.

February 25, 2009

'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas.

February 27, 2008

The effects of a mid-day nap on the neurocognitive performance of first-year medical residents: a controlled interventional pilot study.

December 19, 2012

Interprofessional learning for medication safety.

July 9, 2014

February 26, 2020

Enhancing communication in surgery through team training interventions: a systematic literature review.

December 22, 2010

Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.

March 21, 2018

Are they safe in there? Patient safety and trainees in the practice.

February 8, 2012

Clinical progress note: situation awareness for clinical deterioration in hospitalized children.

May 11, 2022

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.

April 27, 2022

Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit.

May 30, 2007

Use of maternal early warning trigger tool reduces maternal morbidity.

April 6, 2016

Overcoming human barriers to safety event reporting in radiology.

March 6, 2019

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

March 13, 2013

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

January 3, 2007

Related Resources

Top 10 Patient Safety Concerns.

March 12, 2024

Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.

May 17, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 11, 2023

Crisis preparedness: a systems-based framework for avoiding harm in surgery.

November 30, 2022

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Guidance for Industry.

May 25, 2022

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.

May 5, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Quality & safety in the time of coronavirus--design better, learn faster.

July 1, 2020

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

May 27, 2020

Using Safety-II and resilient healthcare principles to learn from Never Events.

April 8, 2020

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

January 29, 2020

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.

December 18, 2019

Patient Safety Primers

Human Factors Engineering

September 7, 2019

People, systems and safety: resilience and excellence in healthcare practice.

April 17, 2019

Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.

April 13, 2019

Exploring the human factors of prescribing errors in paediatric intensive care units.

March 27, 2019

Fixed-dose combination antihypertensives and risk of medication errors.

October 3, 2018

Improving medication-related clinical decision support.

March 7, 2018

Behind Human Error, Second Edition.

November 10, 2017

WebM&M Cases

Complaints as Safety Surveillance

September 1, 2016

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

August 24, 2016

Hospital at night: an organizational design that provides safer care at night.

August 10, 2016

The problem with root cause analysis.

July 13, 2016

See More About The Topic

Quality and Safety Professionals

Safety Scientists

Medication Errors/Preventable Adverse Drug Events

Active Errors

Root Cause Analysis

Integrating systemic accident analysis into patient safety incident investigation practices.

Human Factors Engineering

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Integrating systemic accident analysis into patient safety incident investigation practices.

Human Factors Engineering

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site