The Problem with Traditional Accident Models to Investigate Patient Safety Incidents in Healthcare

  • Gulsum Kubra KayaEmail author
  • Halime Tuba Canbaz
Conference paper
Part of the Lecture Notes in Management and Industrial Engineering book series (LNMIE)


In healthcare, a number of patients experience incidents, where accident models have been used to understand such incidents. However, it has been often traditional accident models used to understand how incidents might occur and how future incidents can be prevented. While other industries also use traditional accident models and built incident investigation techniques based on the traditional models, such models and techniques have been criticised to be insufficient to understand and investigate incidents in complex systems. This paper provides insight into the understanding of patient safety incidents by highlighting the problems with traditional accident models to investigate patient safety incidents, and gives a number of recommendations. We hope that this paper would trigger further discussions on the fundamental concept of the incident investigations in healthcare.


Accident models Incident investigation Patient safety 


  1. Alm, H., & Woltjer, R. (2010). Patient safety investigation through the lens of FRAM. In D. de Waard, A. Axelsson, M. Berglund, B. Peters, & C. Weikert (Eds.), Human factors: A system view of human, technology and organisation (pp. 153–165). Maastricht, The Netherlands.Google Scholar
  2. Baker, G. R. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170, 1678–1686.CrossRefGoogle Scholar
  3. Barach, P., & Small, S. D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ, 320(7237), 759–763.CrossRefGoogle Scholar
  4. Card, A. J. (2017). The problem with ‘5 Whys’. BMJ Quality and Safety, 26, 671–677.CrossRefGoogle Scholar
  5. Carthey, J. (2013). Understanding safety in healthcare: The system evolution, erosion and enhancement model. Journal of Public Health Research, 2(e25), 144–149.Google Scholar
  6. Center for Chemical Process Safety. (2010). Incident investigation phase an illustration of the FMEA and HRA methods. In Guidelines for hazard evaluation procedures, (3rd ed., pp. 435–50). Hoboken, NJ: Wiley.Google Scholar
  7. Chatzimichailidou, M. M., Ward, J., Horberry, T., & Clarkson, P. J. (2017). A comparison of the bow-tie and STAMP approaches to reduce the risk of surgical instrument retention. Risk Analysis.Google Scholar
  8. Clay-Williams, R., & Colligan, L. (2015). Back to basics: Checklists in aviation and healthcare. BMJ Quality and Safety, 24, 428–431.CrossRefGoogle Scholar
  9. Clay-Williams, R., Jeanette, H., & Hollnagel, E. (2015). Where the rubber meets the road: Using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines. Implementation Science, 10, 125.Google Scholar
  10. Davies, P. (2014). The concise NHS handbook. London: NHS Confederation.Google Scholar
  11. Dekker, S. (2002). The field guide to human error investigations. Aldershot: Ashgate.Google Scholar
  12. England, N. H. S. (2015). Serious incident framework: Supporting learning to prevent recurrence. London: NHS England.Google Scholar
  13. Hayes, C. W., Batalden, P. B., & Goldmann, D. A. (2014). A ‘work smarter, not harder’ approach to improving healthcare quality. BMJ Quality and Safety, 24, 100–102.CrossRefGoogle Scholar
  14. Heinrich, H. W. (1931). Industrial accident prevention: A scientific approach. New York: McGraw-Hill.Google Scholar
  15. Hollnagel, E. (2004). Barriers and accident prevention. Surrey: Ashgate.Google Scholar
  16. Hollnagel, E., Hounsgaard, J., & Colligan, L. (2014). FRAM—The functional resonance analysis method—A handbook for the practical use of the method. Middelfart.Google Scholar
  17. House of Commons. (2015). HC 886: Investigating clinical incidents in the NHS. London: The Stationery Office.Google Scholar
  18. Huang, Y.-H., Ljung, M., Sandin, J., & Hollnagel, E. (2004). Accident models for modern road traffic: Changing times creates new demands. IEEE International Conference on Systems, Man and Cybernetics, 1, 276–281.Google Scholar
  19. Klockner, K., & Toft, Y. (2015). Accident modelling of railway safety occurrences: The safety and failure event network (SAFE-Net) method. Procedia Manufacturing, 3, 1734–41.CrossRefGoogle Scholar
  20. Landgrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., Sharek, P. J., et al. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124–2134.CrossRefGoogle Scholar
  21. Larouzée, J., & Guarnieri, F. (2015). From theory to practice: Itinerary of reasons’ Swiss Cheese Model. In L. Podofillini, B. Sudret, B. Stojadinovic, E. Zio, & W. Kroger (Eds.), Safety and reliability of complex engineered systems: ESREL 2015 (pp. 817–824). Zurich: Switzerland.CrossRefGoogle Scholar
  22. Lawton, R., & Parker, D. (2002). Barriers to incident reporting in a health care system. Quality & Safety in Health Care, 11, 15–18.CrossRefGoogle Scholar
  23. Leveson, N. (2004). A new accident model for engineering safer systems. Safety Science, 42(4), 237–270.CrossRefGoogle Scholar
  24. Leveson. (2011). Engineering a safer world: Systems thinking applied to safety. Massachusetts: The MIT Press.Google Scholar
  25. Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2016). A systems approach to analyzing and preventing hospital adverse events. Journal of Patient Safety, 1–6.Google Scholar
  26. Luxhoj, J. T., & Kauffeld, K. (2003). Evaluating the effect of technology insertion into the national airspace system. The Rutgers Scholar, 5.Google Scholar
  27. Macrae, C. (2016). The problem with incident reporting. BMJ Quality and Safety, 25, 71–75.CrossRefGoogle Scholar
  28. Mitchell, I., Schuster, A., Smith, K., Pronovost, P., & Wu, A. (2016). Patient safety incident reporting: A qualitative study of thoughts and perceptions of experts 15 years after ‘to err is human’. BMJ Quality and Safety, 25, 92–99.CrossRefGoogle Scholar
  29. Mullai, A., & Paulsson, U. (2011). A grounded theory model for analysis of marine accidents. Accident Analysis and Prevention, 43, 1590–1603.CrossRefGoogle Scholar
  30. NHS. (2015). About reporting patient safety incidents. National Health Service. 2015.
  31. Pawlicki, T., Samost, A., Brown, D. W., Manger, R. P., Kim, G.-Y., & Leveson, N. (2016). Application of systems and control theory-based hazard analysis to radiation oncology. Medical Physics, 43(3), 1514–1530.CrossRefGoogle Scholar
  32. Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2016). The problem with root cause analysis. BMJ Quality and Safety, 1–6.Google Scholar
  33. Perneger, T. V. (2005). The Swiss Cheese Model of safety incidents: Are there holes in the metaphor? BMC Health Services Research, 5 (71).Google Scholar
  34. Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27, 183–213.CrossRefGoogle Scholar
  35. Reason, J. (1997a). The organisational accident. New York: Ashgate.Google Scholar
  36. Reason. (2000). Human error: Models and management. BMJ, 320: 768–70.CrossRefGoogle Scholar
  37. Reason, J. (1997b). Managing the risks of organisational accidents. Aldershot: Ashgate.Google Scholar
  38. Reason, J., Hollnagel, E., & Paries, J. (2006). Revisiting the Swiss Cheese Model of accidents. Eurocontrol.Google Scholar
  39. Roelen, A. L. C., Lin, P. H., & Hale, A. R. (2011). Accident models and organisational factors in air transport: The need for multi-method models. Safety Science, 49, 5–10.CrossRefGoogle Scholar
  40. Sari, A. B.-A., Sheldon, T. A., Cracknell, A., & Turnbull, A. (2007). Sensitivity of routine system for reporting patient safety incidents in an NHS hospitals: Retrospective patient case note review. BMJ, 334(79).CrossRefGoogle Scholar
  41. Shappell, S. A., & Wiegmann, D. A. (2000). The human factors analysis and classification system-HFACS. Virginia.Google Scholar
  42. Shorrock, S., Young, M., & Faulkner, J. (2005, January). Who moved my (Swiss) Cheese? Aircraft and Aerospace, 31–33.Google Scholar
  43. SIA. (2012). Models of causation: Safety. Victoria: Safety Institute of Australia.Google Scholar
  44. Sujan, M., Spurgeon, P., Cooke, M. Weale, A., Debenham, P., & Cross, S. (2015). The development of safety cases for healthcare services: Practical experiences, opportunities and challenges. Reliability Engineering and System Safety, 140, 200–207.CrossRefGoogle Scholar
  45. Vincent, C. (2007). Incident reporting and patient safety. BMJ, 334(7584), 51.CrossRefGoogle Scholar
  46. Vincent. (2010). Patient safety (2nd ed). Oxford: Wiley Blackwell.Google Scholar
  47. Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world (pp. 1–157). London: Springer Open.Google Scholar
  48. Woodward, S., Randall, S., Hoey, A., & Bishop, R. (2004). Seven steps to patient safety. London: National Patient Safety Agency.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of EngineeringEngineering Design Centre, Cambridge UniversityCambridgeUK
  2. 2.Department of Histology and EmbryologyNecmettin Erbakan UniversityKonyaTürkiye

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