Trainetics' Stefan Sevastru talks systems thinking
The Acute & General Medicine conference is the largest annual conference and exhibition in anaesthesia, surgery, and internal medicine in the United Kingdom. The two-day event is hosted by London Excel and gathers a wide range of clinicians, managers and industry professionals.
The talk challenged the current human-centred retrospective approach to safety in healthcare. As the sociology professor Charles Perrow says: 'we always blame the operator.' Most healthcare organisations still focus on targetting inter-individual variation and correcting human behaviour to reduce error.
This approach proves to be a false economy. On the one side, it is expensive and takes a lot of resources. On the other side, it is futile. Perrow rightly says: 'Humans will always make mistakes. If our systems can't cope with our mistakes, it's hopeless to demand better humans. We need better systems.'
Trainetics advocates for a new system design and incident investigation approach based on the System Engineering Initiative for Patient Safety (SEIPS2). The SEIPS2 is a conceptual framework which allows us to understand that humans are just one small part of a socio-technical system. We work with Tools and Technologies to achieve Tasks in an Internal and External environment. The dynamic and sometimes discrete interactions between these elements generate processes and result in outcomes. Safety interventions must acknowledge and address all these components and their interactions.
Modern safety needs to move from targeting individuals to addressing the whole system. We must move from retrospective approaches to proactive ones, focusing on harm reduction rather than targeting error.