1. CITE THIS CONTENT: KENCEE GRAVES, “SYSTEMS APPROACH TO ERROR”, ACCELERATE UNIVERSITY OF UTAH HEALTH CURRICULUM, JUNE 19, AVAILABLE AT: 

2. ABOUT
THIS LESSON
Medical errors often occur due to system failure, not human failure. This lesson helps explain why we need to evaluate medical error from a system standpoint.
Learning Objectives:
identify medical errors that result from multiple levels of system failure
examine a medical error from the standpoint of a system, rather than an individual
recognize that humans are prone to error; thus, systems must be designed to minimize human error

3. First, what is an “error”?
To understand the systems approach to reviewing medical error, one must first understand what constitutes a medical error. An error is defined as the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.
To understand the systems approach to reviewing medical error, one must first understand what constitutes a medical error. An error is defined as the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.
Reference:
AHRQ Archive. Chapter 1. Understanding Medical Errors (AHRQ | Accessed 30 May 2018) An excellent (and super comprehensive) overview of medical errors.
SOURCE: AHRQ. Accessed online 30 May 2018 at

4. Human Error vs. System Error
Historically, errors in medicine were thought to be caused by a failure on the part of individual providers. In contrast, a systems approach to medical error assumes that most errors result from human failings in the context of a poorly designed system. For example, when seen as a system, a wrong-site surgery performed by a physician who was up all night on trauma call is viewed as the result of the system that failed to protect a patient and provider from error due to fatigue. Without reviewing this as a system, it could be seen as the fault of an individual fatigued provider.
As described by psychologist Dr. James Reason, the defensive layers provided by systems resemble layers of Swiss cheese — except the holes in the cheese are continually changing (Figure 1). The presence of holes in one “slice” does not cause a bad outcome; rather, when the holes in multiple layers of protection line up, harm can come to victims.
References:
AHRQ PSNet Patient Safety Primer: Systems Approach (AHRQ | Accessed 29 May 2018) An expanded version of the content provided in this post, along with a case study, more on Dr. James Reason, and a systems approach to analyzing error.
Human error: models and management (BMJ 2000 | 7 Minutes) Excellent read from Dr. James Reason (the Swiss cheese model maker) that somehow manages to combine Chernobyl, mosquitos, US Navy, and more to tackle error in health care.
DR. REASON’S “SWISS CHEESE MODEL” FOR ERROR.  ERRORS OCCUR WHEN HOLES EXIST IN MANY LAYERS OF SYSTEM DEFENSES.

5. How to Address Systems Failures
Dispel “Shame and Blame.” Embrace a no-blame culture: we all make mistakes.
Report it. It’s critical to submit an event report (“RL” at U of U Health) and provide your perspective on where the system broke down.
Continuously improve. Examine the problem using process-driven learning and prevention methods.
A systems approach to error aims to identify situations or factors that can lead to human error, then work to improve the underlying systems to minimize the likelihood of error or the impact of error.  As Dr. Reason said, “We cannot change the human condition, but we can change the conditions under which humans work.”
DISPEL THE SHAME AND BLAME: The people who delivered the care are often best suited to discuss the steps that led to the outcome. Nursing assistants, nurses, residents, physician assistants, nurse practitioners, therapists, and supervising physicians all play a key role in understanding system breakdowns and identifying solutions that prevent future error.
REPORT IT: Understand that medical errors are common and can happen to anyone. When a medical error occurs, it is critical to submit an event report and provide your perspective on where the system broke down. Use this as an opportunity to identify vulnerabilities in the system and improve processes to prevent a future event.

6. One Method to Try: “Fishbone Diagram”
One method for reviewing a medical error is a Modified Fishbone Diagram.
It is critical to incorporate the perspective of everyone involved to complete the Fishbone Diagram. When conducting a case review, invite people from all roles and levels of experience to help discuss the medical error.
MODIFIED FISHBONE DIAGRAM  COURTESY OF THE UNIVERSITY OF COLORADO MORBIDITY & MORTALITY STEERING COMMITTEE.

7. At the time, was it attributed to an individual(s)?
DISCUSSION
THINK
ABOUT IT
Reflect on an error you (or someone you know) made in a health care setting:
At the time, was it attributed to an individual(s)?
Can you identify ways in which the system broke down?
How might it have been prevented?
For more on this and other topics, explore:
CITE THIS CONTENT: KENCEE GRAVES, “SYSTEMS APPROACH TO ERROR”, ACCELERATE UNIVERSITY OF UTAH HEALTH CURRICULUM, JUNE 19, AVAILABLE AT: 
Reflection adapted from: “Learning from Medical Errors” IHI Open School.