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

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.