Using systems thinking to reduce incidents
SystemsThinking - A New Direction in Healthcare Incident Investigation.
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SystemsThinking - A New Direction in Healthcare Incident Investigation.
The Managing Clinical Risk in Primary Health Care document is designed as a resource for staff in primary health care services. The document has been developed after consultation with practitioners, managers, risk specialists and with reference to the conceptual framework provided by the Victorian Quality Council.
Dignity of risk is another way of saying you have the right to live the life you choose, even if your choices involve some risk.
This 'Dignity of Risk' research project aims to determine policy and decision-makers perceptions of ‘Dignity of Risk’ as it applies to vulnerable older persons living in residential aged care services.
In this No Harm Done podcast, Dr Cathy Balding and Cathy Jones delve into the clinical risk management depths.
This guide is a resource to help support individual and organisational learning and to drive quality improvement, in response to patient safety incidents. Organisations may also choose to use the guide to support quality assurance processes.
As a behaviour change strategy, education rarely achieves the desired result when used on its own. It’s ‛necessary but insufficient’ to effect lasting change. In the classic hierarchy of change effectiveness or the ‘action hierarchy’, education ranks as the least effective intervention, below new rules, policies and more system-focused categories such as forcing functions and automation. And yet, in most human services it continues to be the ‘go-to’ response to everything from accreditation recommendations to policy implementation.
In any ‘system’ – essentially, a collective of different moving parts – we must understand how the parts affect the whole. There are many ways to define ‘Systems Thinking’ – a concept that was first coined by Barry Richmond:
“As interdependency increases, we must learn in a new way. It’s not good enough simply to get smarter and smarter about our particular “piece of the rock.” We must have a common language and framework for sharing our specialized knowledge, expertise and experience with “local experts” from other parts of the web… In short, interdependency demands Systems Thinking. Without it, the evolutionary trajectory that we’ve been following since we emerged from the primordial soup will become increasingly less viable.”
Integrated care addresses the problem of care fragmentation, and instead supports continuity. It is person-centred because it enhances the patient experience through improved coordination of care. Integrated care has been broadly described as an ‘organising principle for care delivery with the aim of achieving improved patient care through better coordination of services provided’ – hence the need for systems thinking.