Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations (12 September 2025)

Summary

This study aimed to assess current use of systems thinking-based strategies by examining a set of Australian patient safety incident investigations.

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.