Hi there,
I have three small children and in the summer we make an annual trip to Fishguard to visit grandparents. We own a couple of kayaks that we strap to the car roof when we go, as part of our holiday activities. Anyone who’s noticed the design of a kayak or had the pleasure of trying to secure one to a roof, will recognise how tricky that convex shape is – you tighten the straps and then they seem to just slip down. This happened to us recently: the kayak came loose and we now have a dented car.
In the moment, it was very tempting to blame my husband for not securing it properly. But as tempting as that was (and I probably did indulge a bit!) I realised we were strapping them differently every time because we had no standardised method, and the kayaks have no built-in attachment points to make securing them straightforward. The “error” was actually a predictable result of poor design and our inconsistent processes.
What this thinking brings to your investigations
This same thinking applies to our investigations too, doesn’t it? The SEIPS (Systems Engineering Initiative for Patient Safety) model helps us look beyond individual actions to examine how the work system as a whole influences what happens. It considers each of the systems elements and how they interact.
Take the task element, for example; I think the lack of standardisation in a task can be a bit of a sign to dig deeper. And often watching how work actually happens is the best way to pick this up.
You know how we talk about ‘work as done’? It can often be misconstrued as the single way work is done. In reality, there can sometimes be huge variety in the way work is done, and this variety isn’t always due to a lack of knowledge (although in our kayak example, that is definitely a factor!).
Sometimes our tasks aren’t obviously designed to have one way to complete them, sometimes the supporting tools don’t support that standardisation. By understanding the reasons behind the variety, that can help us design some more robust recommendations.
Going back to the kayak example, we could recommend some training for my husband and I to complete, or we could acknowledge that kayaks are often transported on car roofs and design some slots into the sides to make even the most basic strapping robust.
The incident you’re investigating might be the visible result of these hidden systemic issues, just like my dented car was the visible result of poor kayak design rather than poor strapping technique.
Try This at Home
Before your next investigation, spend some time noticing systems issues in your non-clinical environment. Look for those moments when you or others create workarounds, when processes vary each time, or when design flaws make errors more likely. Practice spotting the difference between what we’ve always called “human error” and what you can recognise now as a system issue.
Thanks,
Lauren
