| What is the ‘systems approach? |
| Much of the latest research on patient safety takes a systems-thinking approach. There is usually a chain of events, each of which may seem innocuous in itself, leading up to an accident or incident. Viewing the whole system, rather than seeing the final act that led to the accident in isolation, is the approach we now take. This approach looks at the individual practitioner not as a potential culprit to be blamed and shamed in the event of an error, but rather the physician is one actor among a constellation of elements that determine the kind of care the patient receives. For example, the physician is a component of a system that includes the medical record, his assistants, the pharmacist, the technology, and policies he works with and the relations and processes governing the interactions between these elements. Thus, when an error occurs, it is probably not the fault of any one person, but rather it is a consequence of the complex workings of an under-performing system. |
