Still fixing the sharp end: Analysing patient safety incident investigations
Tracks
Room 1
| Wednesday, December 2, 2026 |
| 11:10 AM - 11:30 AM |
| Plenary Room - Grand Central |
Overview
Dr Lorelle Bowditch
Speaker
Dr Lorelle Bowditch
Australian Institute of Health Innovation, Macquarie University
Still fixing the sharp end: Analysing patient safety incident investigations
Abstract
Background/Aim
Despite decades of effort, patient safety incidents (PSIs) remain a significant challenge globally. Incident investigations aim to identify contributing factors (CFs) and generate recommendations to prevent recurrence. Effective recommendations target systems factors that contribute to incidents, however, how investigation teams align CFs to recommendations is poorly understood. This study analysed co-occurrence patterns between CFs and recommendations in Australian PSI investigation reports to determine the extent to which recommendations reflect a system-wide approach to preventing harm.
Methods
PSI investigations (N=300) from 56 Australian health services were examined. CFs and recommendations were classified by healthcare system level (e.g., organisation-level, person-level) using a framework combining Systems Engineering Initiative for Patient Safety (SEIPS) principles and AcciMap’s hierarchy. Incorporating PreventiMap principles, the approach aligned CFs and recommendations within the same hierarchical structure and examined their co-occurrence patterns within reports.
Results
CFs were often identified at the person (47%) and tools and technology (23%) level. Recommendations focused on organisation (50%) and person (30%) levels, and less on the culture, workload, workforce, and workspace (<7% combined). While organisational-level recommendations frequently co-occurred with person (84%) CFs, they were mostly related to policy and procedure change (59%-66%). Issues with the workforce, workload and workspace were also largely addressed through policy changes (54%-74%) and staff focused actions (54%-59%).
Discussion/Implications
Findings reveal a misalignment between CFs and system-focused recommendations. While workforce management, organisational culture, workload and the workspace are recognised drivers of safety in the broader research, they account for <7% of recommendations in this study. When systemic issues like these were identified as contributors to incidents, they were primarily addressed through policy change or targeted staff actions, effectively shifting the burden back to the “sharp end” of the system. Consequently, this strategy remains reactive and fails to proactively address the systemic weaknesses that lead to persistent patient harm.
Despite decades of effort, patient safety incidents (PSIs) remain a significant challenge globally. Incident investigations aim to identify contributing factors (CFs) and generate recommendations to prevent recurrence. Effective recommendations target systems factors that contribute to incidents, however, how investigation teams align CFs to recommendations is poorly understood. This study analysed co-occurrence patterns between CFs and recommendations in Australian PSI investigation reports to determine the extent to which recommendations reflect a system-wide approach to preventing harm.
Methods
PSI investigations (N=300) from 56 Australian health services were examined. CFs and recommendations were classified by healthcare system level (e.g., organisation-level, person-level) using a framework combining Systems Engineering Initiative for Patient Safety (SEIPS) principles and AcciMap’s hierarchy. Incorporating PreventiMap principles, the approach aligned CFs and recommendations within the same hierarchical structure and examined their co-occurrence patterns within reports.
Results
CFs were often identified at the person (47%) and tools and technology (23%) level. Recommendations focused on organisation (50%) and person (30%) levels, and less on the culture, workload, workforce, and workspace (<7% combined). While organisational-level recommendations frequently co-occurred with person (84%) CFs, they were mostly related to policy and procedure change (59%-66%). Issues with the workforce, workload and workspace were also largely addressed through policy changes (54%-74%) and staff focused actions (54%-59%).
Discussion/Implications
Findings reveal a misalignment between CFs and system-focused recommendations. While workforce management, organisational culture, workload and the workspace are recognised drivers of safety in the broader research, they account for <7% of recommendations in this study. When systemic issues like these were identified as contributors to incidents, they were primarily addressed through policy change or targeted staff actions, effectively shifting the burden back to the “sharp end” of the system. Consequently, this strategy remains reactive and fails to proactively address the systemic weaknesses that lead to persistent patient harm.
Biography
Lorelle Bowditch is a Postdoctoral Researcher at Macquarie University’s Centre for Healthcare Resilience and Implementation Science. Following the completion of her PhD in 2025 and drawing on over six years of experience in human factors within safety-critical environments she has focused her expertise on improving the health systems' response to patient harm through an NHMRC Partnership Grant.
