Abstract
Background
Patient Safety increasingly seeks to adopt a systems-based approach. Healthcare has many different environments and dynamics that require exploration and no single methodology or perspective enables practitioners to explore healthcare in its entirety.
Methods
This article explores existing ways in which systems are understood and outlines an alternative approach, the Coherent Framework, to enable understanding of all work systems. To demonstrate this, a seminal patient safety event, the tragic death of Elaine Bromiley following a routine operation is explored through this new approach to demonstrate a flexible, contextual systems approach for all events.
Results
Safety science frequently classifies systems according to the perceived dynamics within it; healthcare is widely considered to be complex. These labels can enable practitioners, but they can also restrict. The Coherent Framework decodes all systems to be irrespective of the degree to which complexity influences work.
Conclusions
The Coherent Framework will enable practitioners to explore how system improvement can be generated by seeking to understand every day work, proactively improving risk management pertaining to patient safety as well as inform learning following a patient safety vent. The Coherent Framework results in practitioners no longer needing to consider if their system is complex, or if it is complex how complex, to instead ask at each moment; what was the degree of complexity influencing agency?
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