My experience as a physician, healthcare mediator and system safety expert has provided me with unique perspectives to investigate and learn from safety-critical events. I have developed the Systemic Nonlinear Analysis Protocol (SNAP), fundamentally shifting the way in which safety data is collected and analyzed.
Adverse patient outcomes are often unpredictable and seldom have a single “root cause”. Using narrative analysis and dynamic contextual mapping helps make sense of patient harm events. This approach enhances engagement at all levels and gathers data that is unavailable using traditional methods of review.