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

Paul M Salmon; Adam Hulme; Guy H Walker; Patrick Waterson; Neville A. Stanton

Commentary

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

May 10, 2023

Salmon PM, Hulme A, Walker GH, et al. Ergonomics. 2023;66(5):644-657.

View more articles from the same authors.

Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.

PubMed citation

Available at

Related Resources From the Same Author(s)

The impact of power on health care team performance and patient safety: a review of the literature.

April 21, 2021

State of science: evolving perspectives on ‘human error’.

March 16, 2022

Understanding complexity in a safety critical setting: a systems approach to medication administration.

April 26, 2023

Applying hierarchical task analysis to medication administration errors.

October 19, 2005

Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.

February 1, 2023

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

A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting.

August 2, 2017

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

June 16, 2021

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

October 28, 2009

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

Integrating systemic accident analysis into patient safety incident investigation practices.

November 21, 2018

A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points.

February 22, 2023

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

October 5, 2022

Quality and safety indicators in anesthesia: a systematic review.

May 27, 2009

Effectiveness of surgical safety checklists in improving patient safety.

April 27, 2016

What has change management in industry got to do with improving patient safety?

January 30, 2005

A new argument for no-fault compensation in health care: the introduction of artificial intelligence systems.

April 7, 2021

Integrating incident reporting into an electronic patient record system.

March 14, 2007

Retrieval of iatrogenic intravascular foreign bodies.

December 5, 2012

Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

January 16, 2008

Improving patient safety in medicine: is the model of anaesthesia care enough?

April 10, 2013

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction.

November 11, 2015

Surgical simulation: a systematic review.

March 8, 2006

Educational opportunities with postevent debriefing.

May 11, 2016

Debriefing in the emergency department after clinical events: a practical guide.

December 17, 2014

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

June 15, 2016

Residual anaesthesia drugs in intravenous lines—a silent threat?

July 17, 2013

Surgical safety checklists: do they improve outcomes?

June 20, 2012

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

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

June 13, 2012

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

March 13, 2019

Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.

March 6, 2005

"Do no harm": promoting anti-racist policing in pediatric emergency departments through 20 practice change considerations.

February 1, 2023

Surgical accountability in the 1880s: the death of Susan Nixon.

August 31, 2005

Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals.

October 16, 2013

Patient reports of undesirable events during hospitalization.

October 12, 2005

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.

February 15, 2012

Why we need a single definition of disruptive behavior.

June 27, 2018

Higher rates of misdiagnosis in pediatric patients versus adults hospitalized with imported malaria.

November 26, 2014

Breaking the rules: understanding non-compliance with policies and guidelines.

September 28, 2011

Patient safety: some progress and many challenges.

November 7, 2012

Patient safety in women's health care: a framework for progress.

April 18, 2007

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

July 15, 2009

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

Intervention to reduce transmission of resistant bacteria in intensive care.

February 1, 2012

Differential impact of a crew resource management program according to professional specialty.

February 15, 2012

Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline.

September 12, 2018

Consumers' perspectives on their involvement in recognizing and responding to patient deterioration—developing a model for consumer reporting.

July 24, 2019

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

December 2, 2009

Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland.

May 23, 2012

Hospital- and system-wide interventions for health care-associated infections: a systematic review.

September 16, 2020

Implementing root cause analysis in an area health service: views of the participants.

November 16, 2005

Perceptual and interpretive error in diagnostic radiology—causes and potential solutions.

September 4, 2019

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Medication assessments by care managers reveal potential safety issues in homebound older adults.

May 18, 2011

Safety skills for clinicians: an essential component of patient safety.

August 20, 2008

Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure.

November 22, 2017

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

Patterns of unexpected in-hospital deaths: a root cause analysis.

March 16, 2011

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study.

June 3, 2015

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

January 5, 2011

Should health care providers be forced to apologise after things go wrong?

January 28, 2015

Patient Safety Innovations

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

September 29, 2021

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

August 24, 2011

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

August 16, 2017

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.

May 9, 2018

A comprehensive departmental care review model: requirements, structure, and flow.

June 30, 2021

Preventing home medication administration errors.

March 14, 2022

A multicenter trial of aviation-style training for surgical teams.

September 15, 2010

Iatrogenic events contributing to ICU admission: a prospective study.

March 24, 2010

Fatal flaws in clinical decision making.

January 30, 2019

To tell the truth: ethical and practical issues in disclosing medical mistakes to patients.

March 6, 2005

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Safer out of hours primary care.

July 7, 2010

Medical liability and patient safety: setting the proper course.

May 18, 2005

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients.

March 24, 2021

Countering cognitive biases in minimising low value care.

June 7, 2017

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

February 8, 2017

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

June 12, 2019

Dispensing errors and counseling quality in 100 pharmacies.

July 15, 2009

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care.

August 5, 2015

Patient engagement in health care safety: an overview of mixed-quality evidence.

November 28, 2018

Weekend mortality for emergency admissions. A large, multicentre study.

February 10, 2010

Improving safety through speaking up: an ethical and financial imperative.

July 24, 2019

Mortality trends after a voluntary checklist-based surgical safety collaborative.

May 3, 2017

Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments.

August 31, 2011

Investigating workplace support and the importance of psychological safety in general surgery residency training.

March 13, 2024

The impact of mobile technology on teamwork and communication in hospitals: a systematic review.

March 20, 2019

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

February 17, 2010

Patient safety climate in primary care: age matters.

March 18, 2009

Shifting supervision: implications for safe administration of medication by nursing students.

November 5, 2008

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

Engineering risk analysis of a hospital oxygen supply system.

April 5, 2006

Related Resources

Top 10 Patient Safety Concerns.

March 12, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

Network of Patient Safety Databases Chartbook.

November 8, 2023

Global Knowledge Sharing Platform for Patient Safety.

September 20, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

August 9, 2023

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.

June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Room of horrors simulation in healthcare education: a systematic review.

June 21, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

April 12, 2023

Perspective

Maternal Safety and Perinatal Mental Health

March 29, 2023

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

March 29, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).

March 22, 2023

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

March 1, 2023

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

February 22, 2023

Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety.

February 22, 2023

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.

February 8, 2023

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report.

February 8, 2023

Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.

February 1, 2023

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

January 25, 2023

See More About The Topic

Researchers

Hospitals

Quality and Safety Professionals

Non-Health Care Professionals

Medicine

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

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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