Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations
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.
Authors
- Raghu Lingam (ORCID: https://orcid.org/0000-0002-0161-793X)
- Samantha Jackson (ORCID: https://orcid.org/0000-0003-2863-8463)
- YU Ying-hua (ORCID: https://orcid.org/0000-0002-8736-0636)
- Lorelle Bowditch (ORCID: https://orcid.org/0000-0002-2783-0595)
- Farah Magrabi (ORCID: https://orcid.org/0000-0002-8426-5588)
- Johanna Westbrook (ORCID: https://orcid.org/0000-0003-1083-8192)
- Peter Damian Hibbert (ORCID: https://orcid.org/0000-0001-7865-343X)
- Charlotte J. Molloy (ORCID: https://orcid.org/0000-0001-7451-9751)
- Masoumeh Abedi (ORCID: https://orcid.org/0000-0003-1844-5844)
- Sandy Middleton (ORCID: https://orcid.org/0000-0002-7201-4394)
- Mia Bierbaum (ORCID: https://orcid.org/0000-0002-7037-4708)
- Virginia Mumford (ORCID: https://orcid.org/0000-0001-7915-0615)
- Robyn Clay‐Williams (ORCID: https://orcid.org/0000-0002-6107-7445)
- Brandon J. King (ORCID: https://orcid.org/0000-0001-6039-5495)
- Paul M. Salmon (ORCID: https://orcid.org/0000-0001-7403-0286)
- Jeffrey Braithwaite (ORCID: https://orcid.org/0000-0003-0296-4957)
- Louise Raggett
Institutions
- NSW Department of Education (AU)
- University of South Australia (AU)
- University of the Sunshine Coast (AU)
- UNSW Sydney (AU)
- St Vincent's Hospital Melbourne (AU)
- Australian Hearing (AU)
- St Vincent's Health (AU)
- St Vincent’s Private Hospital Sydney (AU)
- Australian Catholic University (AU)
- Macquarie University (AU)
Publication Details
- Journal
- BMJ Quality & Safety
- Published
- 2025-09-12
- DOI
- https://doi.org/10.1136/bmjqs-2025-019063
- Citations
- 5
- Primary Topic
- Patient Safety and Medication Errors
- Type
- article
- Field-Weighted Citation Impact
- 12.58