Socio-Technical Safety Investigations in Healthcare - Investigating Human Performance in Modern High Reliability Sector Organizations

摘要

The introduction of the Healthcare Safety Investigation Branch into the National Health Service (NHS) in England is a world first, independent, not for blame investigation approach for healthcare. These investigations are conducted in an environment which has vastly varying levels of socio-technical complexity across a wide geographical region of the United Kingdom (UK) and across Trusts, departments and specialist disciplines. At the heart of this system are the healthcare workers who constantly balance resource to ensure patient safety is maintained to the highest levels. Embedded in a socio-technical system, the human contribution is often providing the adaptability which makes the system work. Historically if patient safety was compromised, or an unexpected outcome occurred it was the human contribution which was scrutinized, often with a view to disciplinary or punitive action in order to prevent recurrence. A more modern approach to system thinking guides us to see the human contribution as only one element of a socio-technical system and possibly the richest source of evidence for fully understanding any event. This pilot study has identified the perceived qualities deemed most valuable for healthcare safety investigators for whom the investigation of human performance will be key to understanding the majority of patient safety events they respond to. Nontechnical skills including communication, Emotional Intelligence, resilience and empathy were ranked above the clinical or technical skills as more important for the individual investigator conducting investigation in healthcare. This is dependent on the clinical and technical expertise being available at a team level to the individual investigator. The initial findings are interesting in that they appear to indicate that as the environment is becoming increasingly socio-technically complex, it is the softer, non-technical (human-centered) skills that are required to understand narrative and context when unexpected outcomes occur in the healthcare setting.