Could System-Focused Incident Review in Healthcare Bridge The Gap Between The "Work-As-Imagined" and The "Work-As-Done"?
(2019) FLMU06 20182Division of Risk Management and Societal Safety
- Abstract (Swedish)
- World Healthcare Organization identifies patient Safety as a global public health concern. Despite concerted efforts made to improve the healthcare system, incidents continues to happen at same rate (Braithwaite, Wears, & Hollnagel, 2015). The most contemporary approaches to safety such as System thinking, and Safety II remain underutilized in healthcare where learning from incidents is mainly conducted using RCA. In the complexity of healthcare organization as dynamic socio-technical system, the effect of applying system thinking and learning from success during incident review is still unknown.
This thesis aims at exploring how system-focused incident reviews that embed the new view of human errors and Safety II could have any impact... (More) - World Healthcare Organization identifies patient Safety as a global public health concern. Despite concerted efforts made to improve the healthcare system, incidents continues to happen at same rate (Braithwaite, Wears, & Hollnagel, 2015). The most contemporary approaches to safety such as System thinking, and Safety II remain underutilized in healthcare where learning from incidents is mainly conducted using RCA. In the complexity of healthcare organization as dynamic socio-technical system, the effect of applying system thinking and learning from success during incident review is still unknown.
This thesis aims at exploring how system-focused incident reviews that embed the new view of human errors and Safety II could have any impact in bridging the gap between “work as imagined” and “work as done”. The study focuses on recommendations related to policies/procedures/guidelines and how those are addressed by policy owner and perceived by the frontline staff. The recommendations at study are from incidents reports resulting from reviews that question the background of the event which include reviewing the policies and procedures. The study includes interviews of both front-line staff involved in the incidents and policy owners responsible of addressing the policies-related recommendations. The aim is to shed light on what factors from the process of learning from incidents (LFI) enables or hinders reconciling the work-as-done (clinical practice) and the work-as-imagined (policies & procedures development).
The study shows that the system-focused incident reviews are appreciated to have helped shed light on many gaps between work-as-imagined and work-as-done, however, the gap is quite dynamic. While fully reconciling the dynamic gap between the WAI and WAD continue to be challenging, the frontline staff find the process of system-focused incident reviews meaningful when it reflects their reality and values their contribution and policy owners find the process of learning from incident meaningful when it studies more than one incident giving them extent of the problems at the sharp end. Other aspects such as compassion and team work were identified lacking in system-focused incident reviews. (Less)
Please use this url to cite or link to this publication:
http://lup.lub.lu.se/student-papers/record/8994089
- author
- Khattabi, Nawal LU
- supervisor
- organization
- course
- FLMU06 20182
- year
- 2019
- type
- H1 - Master's Degree (One Year)
- subject
- keywords
- FLMU06
- language
- English
- id
- 8994089
- date added to LUP
- 2019-09-05 10:51:11
- date last changed
- 2019-09-05 10:51:11
@misc{8994089,
abstract = {{World Healthcare Organization identifies patient Safety as a global public health concern. Despite concerted efforts made to improve the healthcare system, incidents continues to happen at same rate (Braithwaite, Wears, & Hollnagel, 2015). The most contemporary approaches to safety such as System thinking, and Safety II remain underutilized in healthcare where learning from incidents is mainly conducted using RCA. In the complexity of healthcare organization as dynamic socio-technical system, the effect of applying system thinking and learning from success during incident review is still unknown.
This thesis aims at exploring how system-focused incident reviews that embed the new view of human errors and Safety II could have any impact in bridging the gap between “work as imagined” and “work as done”. The study focuses on recommendations related to policies/procedures/guidelines and how those are addressed by policy owner and perceived by the frontline staff. The recommendations at study are from incidents reports resulting from reviews that question the background of the event which include reviewing the policies and procedures. The study includes interviews of both front-line staff involved in the incidents and policy owners responsible of addressing the policies-related recommendations. The aim is to shed light on what factors from the process of learning from incidents (LFI) enables or hinders reconciling the work-as-done (clinical practice) and the work-as-imagined (policies & procedures development).
The study shows that the system-focused incident reviews are appreciated to have helped shed light on many gaps between work-as-imagined and work-as-done, however, the gap is quite dynamic. While fully reconciling the dynamic gap between the WAI and WAD continue to be challenging, the frontline staff find the process of system-focused incident reviews meaningful when it reflects their reality and values their contribution and policy owners find the process of learning from incident meaningful when it studies more than one incident giving them extent of the problems at the sharp end. Other aspects such as compassion and team work were identified lacking in system-focused incident reviews.}},
author = {{Khattabi, Nawal}},
language = {{eng}},
note = {{Student Paper}},
title = {{Could System-Focused Incident Review in Healthcare Bridge The Gap Between The "Work-As-Imagined" and The "Work-As-Done"?}},
year = {{2019}},
}