Overlooking causes in healthcare accident analysis.
Résumé
This paper demonstrates the influence of one's assumptions and angle of analysis on the causes discovered during an accident investigation. The research investigates a real medical case where a physician diagnosed a dislocated shoulder and a pneumothorax on a patient who was subsequently found to only suffer an undisplaced fracture of the shoulder blade and contused ribs. The physician inserted a tube into the thoracic cavity in order to drain the suspected pneumothorax. In doing so, the patient's liver was punctured twice. Three successive analyses of the case were performed: human-centred, organisation-centred, and joint (cognitive and organisation brought together). By comparing analyses, we tested the type of causes of the accident that can be overlooked, and the type of conclusions that can be drawn, depending on the type of analysis performed. We demonstrate the interest in carrying out a joint analysis: it highlights organisational conditions that influence individual behaviour, and therefore minimises the loss of information when looking for explanations. We address the issue of the early decisions and assumptions made in the investigation process. We claim that these determine one's ability to discover complex causes, and have an impact on the capacity of an organisation to protect itself against re-occurrences. Our research discusses these assumptions and lists recommendations that are relevant to the field of accident investigation in the large. As such, our paper can support the work of safety practitioners in a wide range of industrial sectors.
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Besnard-Robson-2010-Overlooking-causes-healthcare-WP-1-CRC.pdf (562.43 Ko)
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