SEIPS in action

Summary

In this blog, Associate Director Claire Cox shares a video training resource developed for the Patient Safety Management Network Symposium. Claire explains how they used it to facilitate an interactive workshop, bringing SEIPS (Systems Engineering Initiative for Patient Safety) to life. 

It's now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action.

Content

One of the highlights of our Patient Safety Management Network (PSMN) symposium, held in September 2024, was the opportunity to bring theory to life through video. Rather than simply talking about systems thinking, we invited participants to see it in action, and to experience how a structured approach such as SEIPS (Systems Engineering Initiative for Patient Safety) can help us understand and improve the realities of care.

How we used the video

The video was shared during the symposium as the centrepiece of an interactive workshop. Before watching, participants were given a brief introduction to the SEIPS framework and an outline of its five key elements:

• Person
• Task
• Tools and Technology
• Organisation
• Environment

With this in mind, the group then watched the video, which depicted a scenario where the flow of work did not entirely match how it might be described in guidelines or procedures. This vividly illustrated the important distinction between Work as Imagined and Work as Done — a theme that ran throughout the symposium.

The workshop exercise

Each participant was given a blank SEIPS template. As the video unfolded, they were asked to note down observations: what did they see that related to each element of the system? For example:

• How were individuals adapting under pressure?
• What tasks created bottlenecks or risks?
• Did tools, technology or equipment support or hinder practice?
• What organisational factors or expectations were visible?
• How did the environment — layout, noise, interruptions — shape the situation?

Crucially, the video did not show an outcome. This was intentional. It meant the group had to consider that the scenario could end in different ways:

A positive outcome, where the patient’s blood samples were sent off on time and care proceeded as planned.

Or a negative outcome, where delays meant the bloods were not sent off on time, potentially affecting the patient’s treatment.

However, the actual outcome does not matter. What matters is that the vulnerabilities in the system — pressures, constraints, workarounds, and risks — were always present. Whether the patient’s bloods were sent successfully or not, those vulnerabilities still shaped the way the work was carried out.

This underlines why observing Work as Done is always beneficial: it allows us to see the realities of practice, understand where systems are fragile, and identify opportunities to strengthen them before harm occurs.

What we learnt

This practical session reinforced some key messages from the symposium:

• Systems thinking is best learnt by doing. A short video can provide a powerful case study to apply frameworks like SEIPS.
• Work as Done is different from Work as Imagined. The gap is not about error or blame, but about understanding the realities of practice and why people adapt in the ways they do.
• Structured tools support richer discussion. The blank SEIPS template acted as both a guide and a prompt, helping participants to organise observations and uncover latent system factors.
• The outcome is secondary to the system. Whether the bloods were sent or delayed, the vulnerabilities in the work system remained. Recognising those vulnerabilities is where real safety improvement begins.

A resource for you

This video and SEIPS exercise is now available as a resource for you to use in your own organisation. It is simple to set up, highly engaging, and encourages teams to think beyond individuals and see the wider system in action. We've pulled together a guide to help people run a training session with the video. 

Training guide and templates

Please feel free to use it with your colleagues — and we would love to hear back from you about how you used it and what the experience was like. Sharing across the network is one of the most powerful ways we can continue to learn together and strengthen patient safety.