Systems Thinking and Patient Safety

	About this book
	Advances in Patient Safety: From Research to Implementation
	Volume 2. Concepts and Methodology
	Sections and articles in Advances in Patient Safety volume 2:
	Systems Thinking and Patient Safety
	Applying Patient Safety Indicators (PSIs) Across Health Care Systems: Achieving Data Comparability
	Validation of AHRQ's Patient Safety Indicator for Accidental Puncture or Laceration
	Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator
	Patient Safety Research in Medical Group Practices: Measurement and Data Challenges
	Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative
	Taxonomic Guidance for Remedial Actions
	The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization
	Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency
	Medical Injury Identification Using Hospital Discharge Data
	Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative
	Development and Implementation of The University of Texas Close Call Reporting System
	Translating Patient Safety Research into Clinical Practice
	Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting
	Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors
	Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words?
	Methodological Challenges in Describing Medication Dosing Errors in Children
	Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings
	Diagnostic Failure: A Cognitive and Affective Approach
	Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project
	Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work
	Clinical Inertia and Outpatient Medical Errors
	A Conceptual Framework for Studying the Safety of Transitions in Emergency Care
	Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology
	Work System Analysis: The Key to Understanding Health Care Systems
	Observing Nurse Interaction with Infusion Pump Technologies
	Usability Testing and the Relation of Clinical Information Systems to Patient Safety
	Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation
	Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities
	A Model-based Approach to Prioritizing Medical Safety Practices
	Creating a Culture of Patient Safety through Innovative Hospital Design
	From Science to Service: A Framework for the Transfer of Patient Safety Research into Practice
	Making a Case for Organizational Change in Patient Safety Initiatives
	Organizational Climate of Staff Working Conditions and SafetyAn Integrative Model
	A Conceptual Model for Disclosure of Medical Errors
	Peer ReviewersVolume 2

Systems Thinking and Patient Safety

Paul M. Schyve

Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that "first, do no harm" has been the ethical watchword throughout the history of medicine, nursing, and pharmacy. In recent years, we have become increasingly aware of the magnitude of our failure to successfully live up to this ethical imperative. We have also become increasingly aware of techniques that we might employ to bring reality closer to the ideal of doing no (preventable) harm.

The realization of the magnitude of this failure and that there are potential routes to reducing harm has fortunately resulted in both a burgeoning of research in the area of patient safety and a willingness to invest in patient safety research. This volumepublished by the Agency for Healthcare Research and Quality (AHRQ) with support from the U.S. Department of Defensealong with its three companion volumes, is testimony to this blossoming of research and funding.

The recent advent of the health care field's emphasis on patient safety came at a favorable time. One or two decades earlier, our response would have been "unenlightened," to say the least; we would not have been able to apply systems thinking to patient safety. Even today, preventable patient harm is too often associated with errorusually human errorboth within health care and, especially, in the medical liability system. Such error is, in the minds of many, to be met with blame and punishment. But systems thinking is now ubiquitous in health caredue, in large measure, to its successful introduction within the context of continuous process improvementwhich provides a much less threatening context than the former reliance on accusations of error. It is this systems thinking that has enabled many in health care move beyond the old (and quite ineffective) "name, blame, and shame" approach to improving safety to a more effective focus on human factors engineering and the systems within which doctors, nurses, pharmacists, and other health care professionals work.

However, systems thinking does not come naturallyespecially to health care professionals. We have been educated and acculturated to recognize our personal responsibility to master the knowledge and skills, and to acquire the wisdom, that enables us to assist sickand often vulnerable and dependentindividuals. We can be sure that Hippocrates and, centuries later, Florence Nightingale, addressed their dictum to "do no harm" to physicians and nurses as individualsnot to the systems within which they worked.

A systems approach to health care safety presents certain new challenges:

(1). It has been said that a system is perfectly designed to produce the output that it produces; or conversely, whatever output we get from a system is what the system is designed to produce

whether the design of the system was planned or unplanned, and whether the results were intended or unintended.

(2). Systems are composed of multiple, interconnected components: people, machines, processes, and data. Each component may directly or indirectly affect not only the function of the system as a whole, but also the functions of other components.

(3). The goal of a system is to maximize the output of the system, not the output of each of its components. Years ago, an engineer pointed out that one could build a car from the then "best" engine, carburetor (it was many years ago), drive train, suspension, and tires

but it would be unlikely to run. Every system, including those in health care, must optimize

rather than maximize

the performance of each of its components in order to maximize the system's output.

(4). The output of a system has multiple dimensions. In health care, the dimensions of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity are often used to describe the output of the system. But it is uncommon for any system to maximize the level of every one of the multiple dimensions of its output; rather, the system must optimize the level of each dimension. This optimization is a value judgment by those who design the system, who manage the system, and who use the output of the system. And these three parties, the stakeholders in the system, do not always agree on the relative priorities for the dimensions of the system's output.

(5). Most systems are open systems; that is, they are affected by

even dependent upon

larger systems of which they are a part and, in turn, they provide inputs to the larger systems. In health care, we have learned the value of studying and changing Microsystems; the people, machines, and data at the level of direct patient care (the treatment team within the hospital or the physician office practice, for example). But these microsystems are subsystems within macrosystems; the organizations such as hospitals, nursing homes, and clinics of which the microsystems are components. Of course, these macrosystems are part of the megasystem of U.S. health care, which itself is a component of the even larger economic and social metasystems of American society as a whole.

(6). Complex systems (and even the microsystems of health care are complex) and open systems are both at risk of producing unintended consequences. Even apparently "inconsequential" changes in health care microsystems and macrosystems will almost always produce unintended consequences. While it is predictable that unintended consequences will emerge, what those consequences will be

and whether they will be beneficial or deleterious

is often unpredictable.

As a result, while systems thinking enables new and productive approaches to improving patient safety, it brings with it its own conceptual challengeschallenges that, if not recognized and addressed, will both slow our progress and introduce new harm.

These challenges require that we learn more about how to apply systems thinking to health care, through answering such questions as: What are the microsystems and macrosystems in health care? How can their performance be measured? How do they interact? What are their vulnerabilitiesand strengths? What are the strengths and weaknesses of each component that comprises the system? How can those strengths and weaknesses compensate for each other within the larger system? How can the functions of each component be optimized so that the results of the system are maximized? How can we identify and monitor for unintended consequences? How can we intervene to prevent harm from unintended consequences?

Many of these questions are the direct or indirect foci of the articles in this volume on "Concepts and Methodology." It is worthwhile to step back from the results of the specific research studies, intervention methods, and tools that are reported in other volumes of this compendium, and, instead, to ask these fundamental questions that are derived from systems thinking. The answers to these questions help us to frame the questions that the studies, interventions, and tools attempt to address, and help us interpret and apply the results of those studies, interventions, and tools. The answers to the system questions also remind us of the complexity that is sometimes hidden in the results of other studies.

One of these complexities is that the "systems" we describe or plan are really only mental models of the real world and how it works. No matter how close to complete and accurate our model may be, it is never entirely complete and entirely accurate. And, no matter how useful our model is, it will never answer every relevant question that we can frame. That is why different ways of measuring a system's components and outputs may lead to different findingseven to apparently contradictory findingsand why different ways of analyzing these findings can lead to different conclusions about how the system works or how it can be redesigned to make it safer. The articles in this book describe various measurement methodologies, various event taxonomies, various reporting systems, and various analytic techniques. In reviewing these articles, the first question should not be. Which approach is better? but, rather, What can we learn from each? and How can they complement each other? In fact, some of the articles explicitly explore the utility of employing multiple methods (e.g., a variety of analytic techniques) simultaneously. Sometimes, however, limitations on resources require selection among the various methods available. When selection becomes necessary, understanding what each method tells usand what it does notbecomes critical in making wise choices among the methods that best answer the questions at hand.

Employing a systems approach to reducing harm in health care also has led to a rethinking of the role of peopleincluding physicians, nurses, and pharmacistswithin the system. This reconsideration leads to such questions as: What are the human vulnerabilities with respect to our capacity to keep up with new knowledge, to remember, or to analyze large amounts of data? How might the principles of distributed cognition and information technology protect us from these vulnerabilities? What are the human vulnerabilities with respect to maintaining motor and cognitive skills in the face of distractions or fatigue? How might system redesignincluding improved use of detection and alarm systemsprotect us from these risks? What are the human vulnerabilities with respect to our thinking, emotions, and actions? How can we compensate for these often unconscious biases? Some of these questions are addressed in the sections on cognition and risk.

This new systems-based understanding of health care harm and how to prevent it will go for naught if we are unable to translate the new knowledge into new practice. Articles that explore organizational issues focus our attention on the important role that the "learning organization" and a "culture of safety" play in implementingand maintainingnew processes and practices. An article derived from discussions of the Dissemination Subcommittee of the AHRQ Patient Safety Research Coordinating Center's Steering Committee provides a comprehensive systems view of the steps in translating research into practice.

The contributions to this volume display both the complexity of a systems approach to patient safety, and the promise of new pathways in thinking about the systems within which health care professionals work and the roles those individuals play as part of these systems. We hope these new pathways of thought will enable us to meet our obligation in health care to "first, do no harm."