Healthcare System Safety

Safety Investigations of Critical Incidents

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.

Accountability Assessments

Accountability is both a valued concept and a misunderstood principle in healthcare. When something unexpected happens, organizations want to know why and how it occurred. Far too often this is framed as “who is responsible for the harm event?” Before assigning blame, it is important to ask about three questions:

  • Were the involved individuals or teams capable of intervening?
  • Did the involved individuals or teams have access to the necessary resources?
  • Finally, did they have the requisite authority to intervene?

An accountability assessment uses narrative analysis to help organizations untangle these important questions, thus promoting learning that informs practice change.

System Safety Training

The SNAP approach and the SPHERE workshop promote skills to provide effective safety investigations.

For more information go to Training and Coaching

Contact us to learn about integrating these methods into your safety program.