Integrating systemic accident analysis into patient safety incident investigation practices

Appl Ergon. 2018 Oct;72:1-9. doi: 10.1016/j.apergo.2018.04.012. Epub 2018 Apr 30.


There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual-based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Keywords: Incident analysis; Patient safety; Systemic accident analysis.

MeSH terms

  • Drug Prescriptions
  • Ergonomics
  • Group Processes
  • Humans
  • Hyperglycemia / drug therapy
  • Insulin / administration & dosage
  • Medication Errors / prevention & control*
  • Patient Safety*
  • Root Cause Analysis
  • Safety Management / methods*
  • Stakeholder Participation
  • Systems Analysis*
  • Systems Theory


  • Insulin