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Patient Safety Learning for Healthcare Improvement: Considering the “System Context” in Medico-Legal Cases?

BOWIE, Paul, ROSS, Al, Purchase, Thomas, McNab, Duncan, Hughes, Helen, Donovan, Lauren, Makeham, Meredith and Carson-Stevens, Andrew (2023) Patient Safety Learning for Healthcare Improvement: Considering the “System Context” in Medico-Legal Cases? Journal of Personal Injury Law. ISSN 1472-9490

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Abstract or description

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 focussing 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.

Item Type: Article
Additional Information: This is a pre-copyedited, author-produced version of an article accepted for publication in Journal of Personal Injury Law following peer review. The definitive published version BOWIE, Paul, ROSS, Al, P. et al. (2023) Patient Safety Learning for Healthca
Faculty: School of Health and Social Care > Nursing and Midwifery
Depositing User: Al ROSS
Date Deposited: 02 Oct 2023 13:18
Last Modified: 30 Apr 2024 15:57

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