This thesis examines the application of Systems-Theoretic Accident Model and Processes (STAMP) in healthcare and the analysis of patient safety incidents. Healthcare organisations have a responsibility for the safety of the patients they are treating. This includes the avoidance of unintended or unexpected harm to people during the provision of care. Patient safety incidents, that is adverse events where patients are harmed, are investigated and analysed as accidents are in other safety-critical industries, to gain an understanding of failure and to generate recommendations to prevent similar incidents occurring in the future. However, there is some dissatisfaction with the current quality of incident analysis in healthcare. There is dissatisfaction with the recommendations that are generated from healthcare incident analysis which are felt to produce weak and ineffective remedial actions, often including retraining of individuals and small policy change. Issues with current practice have been linked to the use of Root Cause Analysis (RCA), an analysis method that often results in the understanding of an accident as being the result of a linear chain of events. This type of simple linear approach has been the target of criticism in safety science research and is not felt to be effective in the analysis of incidents in complex systems, such as healthcare. Research in accident analysis methods has developed from a focus on technical failure and individual human actions to consideration of the interactions between people, technology and the organisation. Accident analysis methods have been developed that guide investigations to consideration of the whole system and interactions between system components. These system approaches are judged to be superior to simple linear approaches by the research community, however, they are not currently used in healthcare incident investigation practice. The systems approach of STAMP is felt to be a promising method for the improvement of healthcare incident analysis. STAMP strongly embodies the concepts of systems theory and analyses human decision-making. The application of STAMP in healthcare was investigated through three case studies, which applied STAMP in: 1. The analysis of the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005-2009. 2. The analysis of a common small-scale hospital-based medication prescription error. 3. The analysis of patient suicide in the community-based services of a Mental Health Trust. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP and discussion of the STAMP applications against criteria for accident analysis models and methods. Healthcare stakeholders were generally positive about the utility of STAMP, finding it to provide a system view and guide consideration of interactions between system components. They also felt it would help them generate recommendations and were positive about the future application of STAMP in healthcare. However, many felt it to be a complicated method that would need specialist expertise to apply. The STAMP applications demonstrated the ability of STAMP to consider the whole system and guide an analysis to the generation of recommendations for system measures to prevent future incidents. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare. The research also discusses the other factors that influence incident analysis beyond that of the analytical approach used and how these need to be considered to maximise the effectiveness of STAMP.

Le vieillissement observé dans la population est souvent responsable de déficits amenant une perte d’autonomie, et une situation de handicap plus ou moins importante. Ces difficultés n’ont pas toujours de possibilités thérapeutiques (i.e. médicamenteuses ou chirurgicales). En revanche, il faut pouvoir soigner, diminuer ou neutraliser ces symptômes. Les technologies numériques semblent pouvoir jouer un rôle sur certaines manifestations du vieillissement en aidant, en assistant, en stimulant, en rééduquant, et, in fine, fournir davantage de qualité de vie et d’autonomie.Cependant, cette nouvelle opportunité a du mal à trouver sa place auprès des seniors, pour des raisons aussi diverses que complexes. En effet, la mise en place, l’organisation, l’évaluation, l’acceptation, le diagnostic, etc. sont autant d’obstacles à l’intégration des technologies. Toutefois, on remarque que le frein le plus important semble être la conception de ces technologies elles-mêmes. Effectivement, pour concevoir, les professionnels doivent avoir de multiples compétences et savoir analyser les besoins, poser des diagnostics compliqués avec des tableaux cliniques et environnementaux multiples (i.e. polypathologie, polyhandicap, évaluation de l’environnement, etc.), pour fournir l’ensemble des solutions ergonomiques, techniques et technologiques possibles. Pour autant, les profils orientés conception (i.e. informaticiens, ingénieurs, architectes, etc.) auxquels appartiennent, au final, la conception et la fabrication des technologies, ont peu de compétences d’évaluation globale et multidimensionnelle d’un sujet en perte d’autonomie et de son environnement.Cette thèse a pour objectif d’apporter un outil informatique capable d’être une aide concrète pour les professionnels de la santé, de la réinsertion et de la conception, en leur proposant une méthodologie d’analyse des déficits sous forme d’un profil précis des potentiels, des freins, et de l’environnement. Pour cela, notre travail tient compte de la pluridisciplinarité des professionnels, et de la complexité de l’évaluation gériatrique.Notre démarche est basée sur un outil informatique ayant plusieurs avantages : d’une part, donner une check-list afin d’être au maximum exhaustif dans l’évaluation des déficits liés à l’âge et ainsi éviter les erreurs ou les oublis lors de l’évaluation. D’autre part, permettre une standardisation par l’administration de tests précis, et ainsi donner un profil à la fois quantitatif et qualitatif de la personne et de son environnement. Enfin, notre méthodologie fournit également une évaluation des systèmes technologiques destinés aux seniors. Notre système, baptisé DAD « Design for Adapted Device » est conçu selon un modèle de conception centré utilisateurs. Nous avons consulté en préconception nos utilisateurs primaires (i.e. sujets âgés), et nous avons relevé dans notre état de l’art les tests d’évaluation de références. Ensuite, nous avons mis au point plusieurs prototypes que nous avons testés auprès de nos utilisateurs secondaires (i.e. professionnels du diagnostic). Enfin, nous avons conçu notre logiciel dans sa version finale, et nous avons soumis des professionnels de la gérontologie (i.e. des professionnels médico-sociaux et des profils orienté conception) à des tests face à des patients. Les résultats issus de nos tests sont très encourageants et suggèrent que notre outil est fidèle et valide.L’outil devrait sensibiliser, inciter et guider les différents producteurs de technologies (i.e. industriel, designer, informaticien ingénieur, etc.), ainsi que les acteurs de santé (i.e. médecin, infirmier, kinésithérapeute, ergothérapeute, psychologue, etc.) à intégrer les personnes âgées dans leur prise en charge, dans leurs décisions, ou dans les différents projets qu’ils envisagent de mettre en place (e.g. conception, prescription, suivi, etc.). / The observed aging of the population is often responsible of deficits causing a loss of autonomy & handicap situation which turns to be more and more important. The encountered difficulties do not always have therapeutic alternatives (i.e. neither through drugs nor surgery). However, having the symptoms treated, reduced or neutralized is a must. The digital technologies seem capable to play a role on aging consequences, on quality of life & autonomy helping, assisting, stimulating, reeducating elderly population.Nevertheless, the digital opportunity does not seem to have success among elderly people for many different & complex reasons. Fair to underline that challenges are faced while trying to integrate these technologies : set up, organization, assessment, acceptance, diagnosis etc. The biggest challenge though remains the design of the technology itself. In fact, professionals need to have multiple competences and know how to analyze requirements, diagnose through multiple clinical & environment situations (multiple pathologies, multiple disabilities, environment assessment, etc.) in order to propose exhaustive ergonomic, technical & technological solutions. Having this said, the profiles who are design oriented (e.g. IT, engineers, architects, etc.) and who own the design & build of the technologies have limited capacities in global, multidimensional assessment on autonomy loss & its environment.Our thesis aims at proposing a digital device able to help concretely professionals specialized in healthcare, reintegration, and design while providing a methodology to analyze deficits through precise profiling of environment, potentials and constraints. That is the reason why, our work considers professionals’ multidisciplinary, geriatrics complex assessment.Our approach consists on an IT device with has multiple advantages: a check list in order to evaluate deficiencies linked to aging and prevent mistakes or omissions during the assessment ;a standardization through precise testing ;a definition of a qualitative & quantitative profile of the person and the environment ;a strong assessment of the digital technologies focusing on elderly population.Our tool, named DAD « Design for Adapted Device » was designed according to a model focusing on users. At the very first step of the design, primary users (i.e. elderly patients) were consulted and in the conceptual framework, we picked the gold standards. Then, we launched several prototypes which were subjects to testing by our secondary users (i.e. diagnosis professionals). Last but not least, we designed the final version of our tool and we had gerontology professionals (medico-social professionals & design oriented profiles) going through tests in front of patients. Our testing results looked encouraging and suggest that our tool is reliable and valid.The tool should sensitive, encourage and guide the digital actors (such as industrials, designers, IT engineers, etc.) as well as health professionals (such as doctors, nurses, physiotherapists, ergotherapists, psychologists, etc.) to strongly consider elderly patients in their therapeutic approaches, in their decision making or in their different to-be projects (e.g. design, prescription and follow up, etc.).