Human Factors Hub

In this commentary, Prof Paul Bowie and colleagues representing healthcare, legal, academic and patient, carer and family organisations explain how and why highly complex care systems generally fail and introduce and debate the potential role of Systems Thinking in related medico-legal cases.

Abstract

Patient safety incidents occur across all healthcare settings worldwide. Patients, families and carers can be physically and psychologically traumatised and often experience additional and prolonged harms due to a lack of apology, openness and transparency. Healthcare professionals can also be emotionally impacted and subject to embarrassment, guilt, complaints, regulatory investigations and medico-legal action. Despite significant healthcare policy and professional attention, evidence of related learning and successful risk reductions at all levels are severely limited. In this article, rather than focusing on the individual “failings” of professionals, we take a Human Factors systems perspective in explaining how and why highly complex systems generally fail. We introduce a series of Systems Thinking principles for potentially guiding more meaningful discussions and learning from when things go wrong in highly complex sociotechnical systems, such as much of healthcare. We suggest to the medico-legal community whether a debate is needed around the need for the judiciary, expert witnesses, regulators and legal professionals to be better informed in the Human Factors “systems approach” to patient safety investigations as part of the medico-legal process.