Using systems thinking in patient safety: a case study on medicines management
Evidence & Practice    

Using systems thinking in patient safety: a case study on medicines management

Mandy Brimble Lecturer and director of undergraduate studies, School of Healthcare Sciences, Cardiff University, UK
Aled Jones Senior lecturer, School of Healthcare Sciences, Cardiff University, UK

Systems thinking is used as a way of understanding behaviours and actions in complex healthcare organisations. An important premise of the concept is that every action in a system causes a reaction elsewhere in that system. These reactions can lead to unintended consequences, sometimes long after the original action, and so are not always attributed to them. This article applies systems thinking to a medicines management case study, to highlight how quality-improvement practitioners can use the approach to underpin planning and implementation of patient-safety initiatives. The case study is specific to transcribing in children's hospices, but the strategies can be applied to other areas. The article explains that, while root cause analysis tools are useful for identifying the cause of, and possible solutions to, problems, they need to be considered carefully in terms of unintended consequences, and how the system into which the solution is implemented can be affected by the change. Analysis of problems using a systems-thinking approach can help practitioners to develop robust and well informed business cases to present to decision makers.

Nursing Management. doi: 10.7748/nm.2017.e1621


Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Received: 27 February 2017

Accepted: 02 May 2017

Published online: 05 June 2017

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