Early warnings, weak signals and learning from healthcare disasters

Abstract

In the wake of healthcare disasters, such as the appalling failures of care uncovered in Mid Staffordshire, inquiries and investigations often point to a litany of early warnings and weak signals that were missed, misunderstood or discounted by the professionals and organisations charged with monitoring the safety and quality of care. Some of the most urgent challenges facing those responsible for improving and regulating patient safety are therefore how to identify, interpret, integrate and act on the early warnings and weak signals of emerging risks-before those risks contribute to a disastrous failure of care. These challenges are fundamentally organisational and cultural: they relate to what information is routinely noticed, communicated and attended to within and between healthcare organisations-and, most critically, what is assumed and ignored. Analysing these organisational and cultural challenges suggests three practical ways that healthcare organisations and their regulators can improve safety and address emerging risks. First, engage in practices that actively produce and amplify fleeting signs of ignorance. Second, work to continually define and update a set of specific fears of failure. And third, routinely uncover and publicly circulate knowledge on the sources of systemic risks to patient safety and the improvements required to address them.

Recurring themes in the legacy of Jens Rasmussen

“…'distributed cognition' the use of graphical representations to solve problems and the theory of mental models - Hutchins, 1995;Scaife and Rogers, 1996;Johnson-Laird, 1983). Similar parallels can be drawn with other parts of the paper which read today like early descriptions of the use of 'early warnings and 'weak signals' (Macrae, 2014) or implicit memory (Broadbent et al, 1986) (Rasmussen and Jensen, 1974: 296).…”

On safety ontology: a cross-section analysis of incident investigations in a public healthcare system

“…However, this example of human behaviour also opens a discussion on alternative pathways for conducting incident investigations in the healthcare field. Other organisations in society, and recently even healthcare systems, have established the use of independent investigation teams to ensure that unfiltered and system-wide causal factors are identified [30,31]. The traditional idea of adverse event causation that emphasises decomposition or reduction into malfunctioning system components was for decades the major theory in activities enhancing safety.…”

Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness

“…There are difficult challenges in learning from patient safety incidents; analysts do not have complete information, they must determine which incidents are preventable and make inferences about likely causes and optimal intervention strategies (Macrae, 2014). Learning has been termed a process of sense making as analysts piece together information to make inferences about actions they can take to improve safety (Battles et al, 2006 Surprisingly, the process undertaken by teams to analyse incidents has been the subject of few in depth studies (Lukic et al, 2010).…”