With increasingly complex safety-critical systems like healthcare being developed and managed, there is a need for a tool that allows us to understand their complexity, design better strategies and guide effective change. System dynamics (SD) has been widely used in modelling across a range of applications from socio-economic to engineering systems, but its potential has not yet been fully realised as a tool for understanding trade-off dynamics between safety and efficiency in healthcare. SD has the potential to provide balanced and trustworthy insights into strategic decision making. Participatory SD modelling and learning is particularly important in healthcare since problems in healthcare are difficult to comprehend due to complexity, involvement of multiple stakeholders in decision making and fragmented structure of delivery systems. Participatory SD modelling triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. It provides decision-makers with an evaluation and learning tool to analyse impacts of changes and determine which input data is most likely to achieve desired outcomes. This thesis aims to examine the feasibility of applying participatory SD modelling approach to safe and efficient staffing level management within hospital pharmacies and to evaluate the utility and usability of participatory SD modelling approach as a learning method. A case study was conducted looking at trade-offs between dispensing backlog (efficiency) and dispensing errors (safety) in a hospital pharmacy dispensary in an English teaching hospital. A participatory modelling approach was employed where the stakeholders from the hospital pharmacy dispensary were engaged in developing an integrated qualitative conceptual model. The model was constructed using focus group sessions with 16 practitioners consisting of labelling and checking practitioners, the literature and hospital pharmacy databases. Based on the conceptual model, a formal quantitative simulation model was then developed using an SD simulation approach, allowing different scenarios and strategies to be identified and tested. Besides the baseline or business as usual scenario, two additional scenarios (hospital winter pressures and various staffing arrangements, interruptions and fatigue) identified by the pharmacist team were simulated and tested using a custom simulation platform (Forio: user-friendly GUI) to enable stakeholders to play out the likely consequences of the intervention scenarios. We carried out focus group-based survey of 21 participants working in the hospital pharmacy dispensaries to evaluate the applicability, utility and usability of how participatory SD enhanced group learning and building of shared vision for problems within the hospital dispensaries. Findings from the simulation illustrate the knock-on impact rework has on dispensing errors, which is often missing from the traditional linear model-based approaches. This potentially downward-spiral knock-on effect makes it more challenging to deal with demand variability, for example, due to hospital winter pressures. The results provide pharmacy management in-depth insights into potential downward-spiral knock-on effects of high workload and potential challenges in dealing with demand variability. Results and simulated scenarios reveal that it is better to have a fixed adequate staff number throughout the day to keep backlog and dispensing errors to a minimum than calling additional staff to combat growing backlog; and that whilst having a significant amount of trainees might be cost efficient, it has a detrimental effect on dispensing errors (safety) as number of rework done to correct the errors increases and contributes to the growing backlog. Finally, capacity depletion initiated by high workload (over 85% of total workload), even in short bursts, has a significant effect on the amount of rework. Evaluative feedback revealed that participatory SD modelling can help support consensus agreement, thus gaining a deeper understanding of the complex interactions in the systems they strive to manage. The model introduced an intervention to pharmacy management by changing their mental models on how hospital winter pressures, various staffing arrangements, interruptions and fatigue affect productivity and safety. Although the outcome of the process is the model as an artefact, we concluded that the main benefit is the significant mental model change on how hospital winter pressures, various staffing arrangements, interruptions and fatigue are interconnected, as derived from participants involvement and their interactions with the GUI scenarios. The research contributes to the advancement of participatory SD modelling approach within healthcare by evaluating its utility and usability as a learning method, which until recently, has been dominated by the linear reductionist approaches. Methodologically, this is one of the few studies to apply participatory SD approach as a modelling tool for understanding trade-offs dynamics between safety and efficiency in healthcare. Practically, this research provides stakeholders and managers, from pharmacists to managers the decision support tools in the form of a GUI-based platform showcasing the integrated conceptual and simulation model for staffing level management in hospital pharmacy.

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.

The quality issue of provided health care is the topic which is constantly getting more attention. In this area there is always even probably will be always - something to improve. The patients´ safety in healthcare facilities is affected by the so-called culture of safety.The research was conducted in six medical institutions of the South Bohemian Region, though seven were originally planned. However, I was not given the data here, probably due to the long term incapacity of the respondent. The research was focused precisely on the area of care quality and patient safety. A mixed method research (qualitative and quantitative) was deliberately used in this task. The aim was to map the most common causes of adverse events and then, based on the causes, to propose possible arrangements to prevent the occurrence of the causes. For this purpose five research questions were established.The outcomes obtained were processed into tables, plus the graphical representation of some was accompanied. Then, in the "discussion" chapter, the results were compared and analyzed in more detail.

Cette recherche s’inscrit dans le domaine de la gestion des risques et de la sécurité des patients, et vise à développer une méthode d’analyse de la fragilisation de l’activité pour faire face aux difficultés méthodologiques rencontrées par les centres de radiothérapie pour mener une analyse des risques encourus par les patients à partir de la méthode AMDEC. Cette thèse est une contribution empirique et théorique sur la « sécurité en réflexion » dans des espaces de discussion (régulation froide) que l’on distingue ici de la « sécurité en action » (régulation chaude). Ce travail cherche à déterminer de nouveaux liens entre la sécurité et la gestion des risques – relation éminemment connectée mais également chargée d’ambiguïtés – en donnant une place prépondérante à une étape méthodologique souvent délaissée, l’identification des risques. La sécurité des soins dépendant principalement des pratiques quotidiennes exercées par le personnel soignant, il s’agirait pour les analystes de faire le lien entre un risque générique facilement identifiable – par exemple, la surexposition des patients à des rayonnements ionisants – et sa construction, sa propagation dans le travail réel de l’équipe soignante. Cette recherche propose de travailler ce lien collectivement dans des « espaces de discussion » mobilisés classiquement par les sciences de gestion pour accompagner un changement ou pour améliorer la performance d’une organisation, et de les adapter pour identifier les risques à partir de l’analyse de la qualité du travail quotidien d’une équipe de radiothérapie. La thèse défendue dans ce travail est la suivante : la sécurité des patients dépend de la production de nouvelles connaissances 1) sur la complexité du travail de l’équipe soignante, 2) sur les modes de réussite mobilisés par les soignants pour résoudre ou contourner les complexités de leurs activités et 3) sur les conditions de fragilisation des modes de réussite. Autrement dit, la finalité de cette analyse des risques serait un recueil de données organisées sur ce qui se passe dans le travail et ce qui l’affecte. Ce recueil viserait à améliorer les informations détenues individuellement sur la complexité du travail collectif transverse, à mettre en visibilité des dimensions plus difficilement accessibles (politique, stratégique, organisationnelle, contextuelle…) et à faire des liens entre les complexités du travail et les risques encourus par les patients à partir d’un objet intermédiaire : les fragilisations des modes de réussite. L’objectif recherché de ces « Espaces de Partage et d’Exploration de la Complexité du Travail » (EPECT) est d’améliorer la connaissance individuelle et collective sur le développement des situations risquées dans le travail et de les partager dans l’équipe pour maximiser la sécurité réelle. La consolidation de l’étape d’identification des risques par une caractérisation et un partage de situations risquées dans le travail devrait améliorer le travail d’équipe et faciliter la maitrise des situations risquées. Le croisement de deux disciplines, l’ergonomie et la gestion des risques a permis d’enrichir les principes méthodologiques portés par chacune d’elle, des moyens de décrire des complexités de l’activité pour l’ergonomie et des situations risquées réelles pour l’ingénierie des risques. Au-delà de ces apports méthodologiques, l’ergonomie a été mobilisée pour élaborer progressivement de nouveaux principes méthodologiques à partir des limites réelles d’anciens principes méthodologiques et pour évaluer la méthode. Le nombre et « l’intensité » des difficultés méthodologiques rencontrées par les utilisateurs pourraient déterminer un lien faible ou fort entre la méthode de gestion des risques mobilisée et la sécurité des patients. Enfin, ce travail a été l’occasion de proposer une évolution du concept de sécurité réglée et de sécurité gérée et une nouvelle définition du risque. / This research is in the field of risk management and patient safety. It aims to develop a methodology for exploring the weakening of real work of a medical team and to cope with methodological difficulties encountered by radiotherapy centers when analyzing patients’ risks incurred the therapeutic process with FMEA method. This thesis is a theoretical and empirical contribution about "safety in reflection" in discussion spaces that is distinguished within "safety in action". This work seeks to identify a new link between safety and risk management by giving a predominant place to a methodological step often neglected: the risk identification. Safety of care depending mainly of day-to-day practices of caregivers, it would be for analysts to make the connection a generic risk (eg. overexposure of patients to radiation) and the construction, the spread in the real work of healthcare team. This research proposes to work this link collectively in discussion spaces classically mobilized by the sciences of management to accompany a change or improve the performance of the organization and to adapt them to identify risks in the daily work of a radiotherapy team. The thesis argues that patient safety depends on the production of a new knowledge: 1) on the complexity of the daily work of the healthcare team, 2) on success modes mobilized to reduce it and 3) on weakening conditions of these success modes. In other words, risk analysis will be a data collection about what is really happening in the daily work and what is affecting it. This data collection would seek to improve information held individually in relation to the complexity of the cross-functional collective work, to make visible dimensions that are difficult to access (politic, strategic, organization, context…) and to make links between complexity of work and risks incurred by patients. The aim of "spaces for sharing and exploring the complexity of work" is to improve individual and collective knowledge on the development of risky situations, to share them in the team in order to maximize the real safety. The interaction between ergonomics and risk management contribute to enrich methodological principles and revise theoretical notions.