A system safety approach to assessing risks in the sepsis treatment process

Designing better systems to navigate the sepsis-antimicrobial stewardship tension

Sepsis is a leading cause of preventable death and requires timely antimicrobial treatment to reduce mortality. Despite extensive sepsis management guidelines, high-income countries continue to have considerable rates of sepsis mortality, indicating a gap between guideline quality, usability, and practical application. Simultaneously, the rise of antimicrobial resistance threatens the efficacy of antimicrobial therapies for infection control, underscoring the tension between sepsis management and antimicrobial stewardship. This Personal View explores how system factors, such as people, environments, tools, technologies, and tasks, influence the sepsis-antimicrobial stewardship tension. With the Systems Engineering Initiative for Patient Safety, we use a case study to highlight how organisational pressures, inadequate diagnostic tools, and sociocultural factors drive the gap between work-as-imagined and work-as-done. These latent safety risks that impede guideline adherence and contribute to unintended antimicrobial use highlight the need to design better systems, not blame individuals for non-compliance. We argue that addressing sepsis and antimicrobial resistance requires a holistic systems approach and that every discipline, including policy makers, clinicians, researchers, and drug developers, should adopt systems thinking in the design of interventions intended to address this problem. This shift is essential to ensuring effective care for patients today while safeguarding the effectiveness of antimicrobials tomorrow.

A systems approach to managing the risk of healthcare acquired infection in an acute hospital setting supported by human factors ergonomics, data science, data governance and AI

Innovative approaches are needed for managing risk and system change in healthcare. This paper presents a case study of a project that took place over two years, taking a systems approach to managing the risk of healthcare acquired infection in an acute hospital setting, supported by an Access Risk Knowledge Platform which brings together Human Factors Ergonomics, Data Science, Data Governance and AI expertise. Evidence for change including meeting notes and use of the platform were studied. The work on the project focused on first systematically building a rich picture of the current situation from a transdisciplinary perspective. This allowed for understanding risk in context and developing a better capability to support enterprise risk management and accountability. From there a linking of operational and risk data took place which led to mapping of the risk pattern in the hospital.

Facilitating the application of systems-theoretic process analysis in healthcare: Creating control structures using process maps

Systems-theoretic process analysis (STPA) is a prospective safety assessment tool increasingly applied in healthcare. A problem hampering STPA proliferation is the difficulty of modeling systems for analysis by creating control structures. In this work, a method is proposed to use existing process maps-commonly available in healthcare-when creating a control structure. The proposed method entails (1) extract information from the process map, (2) determine the modeling boundary of the control structure, (3) transfer the extracted information to the control structure, (4) add additional information to complete the control structure. Two case studies were conducted: (1) ambulance patient offloading in the emergency department and (2) ischemic stroke care with intravenous thrombolysis. The amount of process map-derived information in the control structures was quantified. On average, 68% of the information in the final control structures was derived from the process map. Additional control actions and feedback were added from nonprocess map sources for management and frontline controllers. Despite the differences between process maps and control structures, much of the information in a process map can be used when creating a control structure. The method enables the creation of a control structure from a process map to be done in a structured fashion.

A socio-technical systems analysis of the application of RFID-enabled technology to the transport of precious laboratory samples in a large acute teaching hospital

The scale and pace of improvement in patient safety in healthcare has been unacceptably slow. A paucity of research into the application of systems-thinking concepts and a failure to appreciate health systems complexity are cited as barriers to sustainable health systems improvement. This study reports on a socio-technical systems analysis, called the CUBE, of the characteristics of a large acute teaching hospital's system for the transport of precious specimens, a system enabled by radio-frequency identification tracking technology. The CUBE proved itself to be an effective analytic tool. The analysis provided a constructive framework to link diverse data and documentation; explicitly inviting consideration of the roles and understandings of different stakeholders; as well as broader cultural factors that could influence current or future activity. The analysis also supported recommendations to improve and extend operations. This study supports the argument for systems understanding and systems thinking being at the core of new approaches to patient safety.

Integration of Functional Resonance Analysis with Multicriteria Analysis for Sociotechnical Systems Risk Management

Water reservoirs are considered very important storage facilities for the condition of peak demand in the agriculture industry. The construction process of a water reservoir may be accompanied by multiple risks. This study is aimed at identifying the emerging risks resulting from variability in different functions and at prioritizing them based on the analytical hierarchy process (AHP) method. In fact, the potential variability (emerging risks), possible dependencies/couplings, and the barriers used for damping this variability were assessed using Functional Resonance Analysis Method (FRAM). The AHP method was then applied to prioritize the various functions. The results of FRAM modeling indicated that there was the possibility of a high variability in five functions. In this context, the AHP findings showed that "initial studies on the construction of the pool" with the weight of 0.310 and "excavation" with the weight of 0.308 were the most important functions in this study. In addition, the results of this study demonstrated that AHP may be a desired alternative for the identification of performance variability and the aggregation of variability.

Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient

BACKGROUND

Failure to rescue (FTR) denotes mortality from post-operative complications after surgery with curative intent. High-volume, low-mortality units have similar complication rates to others, but have lower FTR rates. Effective response to the deteriorating post-operative patient is therefore critical to reducing surgical mortality. Resilience Engineering might afford a useful perspective for studying how the management of deterioration usually succeeds and how resilience can be strengthened.

METHODS

We studied the response to the deteriorating patient following emergency abdominal surgery in a large surgical emergency unit, using the Functional Resonance Analysis Method (FRAM). FRAM focuses on the conflicts and trade-offs inherent in the process of response, and how staff adapt to them, rather than on identifying and eliminating error. 31 semi-structured interviews and two workshops were used to construct a model of the response system from which conclusions could be drawn about possible ways to strengthen system resilience.

RESULTS

The model identified 23 functions, grouped into five clusters, and their respective variability. The FRAM analysis highlighted trade-offs and conflicts which affected decisions over timing, as well as strategies used by staff to cope with these underlying tensions. Suggestions for improving system resilience centred on improving team communication, organisational learning and relationships, rather than identifying and fixing specific system faults.

CONCLUSION

FRAM can be used for analysing surgical work systems in order to identify recommendations focused on strengthening organisational resilience. Its potential value should be explored by empirical evaluation of its use in systems improvement.