This short summary is very much about understanding behaviours and motivations within a safety investigation framework.
Daniel Kahneman pioneered the science of behavioural economics and received the Nobel Prize for his work, he developed the concept of “Dual Process Theory” and how humans think fast and slow and how human thinking is affected by heuristics and cognition. It’s about how humans think and make judgements. He identified that there were a wide range of cognitive/thinking biases, cognitive error refers to any errors (SRK) at any level in the hierarchy of thinking processes.
Kahneman & Tversky identified that these were particularly common in medical incidents with clinical error at the centre of those incidents.
When humans think about a problem and a solution, we use heuristic logic, a short cut system. Our brains have evolved to make rapid decisions, a best guess often without considering all the facts before us. It is vital for making quick and sometimes lifesaving decisions. The problem is that clinical decisions often need a more considered approach, this can over time become habitual and leads to errors.
I don’t want to get too heavy on the theories here, there is plenty of information available on the net and also of interest is Dr Pat Croskerry, Dalhousie University who has identified 50 cognitive biases in healthcare.
Humans are part of the sociotechnical system, humans, machines and the organisation operating together. In healthcare it includes people, interactions and relationships as part of a larger thing, operating collectively towards a common purpose.
Safety is a control problem, or can be viewed as such and safety is managed by a control structure. Investigators therefore should be able to identify why the existing control structure failed, or which parts of it failed. To prevent future error requires a control structure that can be designed that will enforce the necessary constraints on the system to ensure safe operation and can continue as such as changes occur.
What then of human error within the sociotechnical system, how do we understand it. Often it is discoverable evidence of the adverse event which leads to a finding of e.g. human error, but what we don’t seem to analyse so well is people’s intentions and behaviours which, do not come about from factual evidence per se, e.g. what motivated our decision or behaviour.
How do we understand this in the context of the investigation, identifying this can be extremely challenging, identifying what motivated how we perceived a situation? However, this can lead to a richer understanding of the influences on human behaviour.
I have been looking at models that can be inserted into a core investigative doctrine for safety and to date I have settled on that posed by Dr Russell Kelsey MB.BS.MRCGP a subject matter expert in serious clinical investigation which places clinical error at the centre of three influences of attitude, attention and cognition and the effects of various biases within those three influences and situational awareness and high pressure environments.
I am not connected to Russell and also do not want to be seen as breaching any copyright within this but more information can be found in his book at https://www.amazon.co.uk/Patient-Safety-Investigating-Reporting-Incidents/dp/1498781160 which I have found very informative.
Has anyone developed a method/model that looks deeper at the context behind human error as I would be interested in the approach. The new PSIRF will transform our approach refocusing on systems, processes and behaviours and whilst early adopters are trialling the framework it does not stifle discussion and consideration for improvements and would be interested of any developments already within investigation management .
Investigations & Learning Specialist- RWHT
Hi, Sorry meant to attach this scoping document have converted to pdf and hope it is of some use. RCA in this method is just an analytical tool and we are moving away from the term root cause Overview Patient Safety Investigations.pdfOverview Patient Safety Investigations.pdf
If the trust owns the data e.g. records, statements from staff etc it is usually not an issue, the questions is raised when a patient/family may have their own material e.g. video/audio/photograps on smartphones or other correspondence such as letters or emails etc. Personaly I would always ensure I have written consent from them to use it. This could be recorded in for example their witness statement saying that they consent to abc using the material for the purposes of the investigation, and what will happen to the material once the investigation is concluded. I would not want want for example an aggrieved party who is not later happy with the investigation outcome to then be using a complaint to the information commissioners on the issue of consent or the retention of data (post) and written is provable where verbal may be a contentious point. All information is subject to GDPR.
Section from Recital 42 GDPR " Where processing is based on the data subject’s consent, the controller should be able to demonstrate that the data subject has given consent to the processing operation. In particular in the context of a written declaration on another matter, safeguards should ensure that the data subject is aware of the fact that and the extent to which consent is given"
I don't think the documents and the detail will be ready until next year buut I have modelled out an approach taken from my own background and researching a number of sources and unapoligetic for plagerising some ideas also.
This short pdf is about my designing of a process that can be adaptive to change and develop some consistency across our trust in due course. I would of course appreciate alternative views, constructive comments and ideas, as I say it lacks areas of detail which I can elaborate on if required as I say just an outline.
KeithPatient Safety Investigations Model design.pdf
I have currently designed an investigation method and a training model which is under consideration with the trust a step/method approach, as soon as it has been agreed I will happily post. It has moved away from RCA per se, but still retaining it as an analytical tool within alongside other approaches. The method looks at investigative foundations, investigative methodology, witness interviewing, support tools and methods of analysis, hierarchy of learning and recomendations, supporting families, staff and establishing what is need for systems change. I am trying to make it a more flexible investigative approach that can respond to incident at hand.
As aluded to above I agree from my time here there are repeated themes/events/learning and beyond this method I want to look at systems contsraints that enforce the necessary behaviour changes e.g. People, Systems and Tasks
Investigations & Learning Specialist
Royal Wolverhampton Trust