Safety of care

Improving patient safety and reducing risks

How “systems thinking” can lead to safe care

Originally published May 2015

The traditional response to a patient safety incident was to identify and blame the providers who had the last contact with the patient, which then led to calls for greater vigilance, better training, and sometimes professional sanctions or dismissals. Systems theory, on the other hand, looks at the system, rather than the individual, to identify problems and prevent future adverse outcomes. This stems from the understanding that preventing patient safety incidents often depends on the environment in which patient care is delivered, as well as the interactions between healthcare providers and patients.

There are many ways to analyze incidents at the system level, including use of retrospective and prospective methods. A culture of safety in which reporting patient safety incidents is encouraged, where analysis of incidents to identify causes is standard, and where healthcare providers are not punished for participating in quality improvement reviews is essential for addressing systemic flaws in healthcare systems.1

The following case example illustrates how the prevention of maternal and fetal harm requires a strategic approach. Such an approach would be comprehensive and involve labour and delivery teams in multiple birthing units and hospital leadership. At the system level, health quality councils, regulatory and accrediting authorities, liability providers, maternal/fetal health collaboratives, and medical education accrediting bodies would also contribute, within their respective areas of responsibility, to improved outcomes.

Case example: System failures result in compromised birth, legal action

A 26-year-old woman with a second pregnancy (G2P1) and who had had a previous Caesarean section is admitted after spontaneous rupture of her membranes at term. Her initial examination reveals a cervix at 2 cm dilation. She elects to undergo a vaginal birth. Over the next 6 hours her contractions decrease in regularity with no further progression of her cervical dilation. The bedside nurse calls the obstetrician who asks her to “start the oxytocin protocol.” The hospital has 2 oxytocin protocols: a low-dose protocol for augmentation of labour, and a high-dose protocol for induction of labour. The nurse and obstetrician do not discuss which protocol to use. The bedside nurse institutes the induction protocol. The obstetrician intended to use the augmentation protocol.

Over the ensuing 3 hours, the nurse regularly increases the infusion rate of the oxytocin. When she reaches the hospital protocol’s maximal oxytocin dose, the nurse elects to continue to increase the dose because she wants to get the contractions as close to every 2 minutes as possible [the latitude is not well outlined in the protocol].

The external fetal monitoring (EFM) strip records the fetal heart rate increasing from a baseline of 130-140 bpm to 160-170 bpm with the appearance of deep variable decelerations from which the fetus recovers spontaneously. The patient later develops a low grade fever and the nurse calls the obstetrician to assess the patient but does not mention the change in the EFM strip. The obstetrician looks at the EFM strip but does not ask about the rate of oxytocin infusion and does not examine the patient. The physician orders antibiotics for the possibility of chorioamnionitis.

Thirty minutes later, the EFM shows a prolonged deep late deceleration which does not recover. An urgent examination reveals palpable fetal parts through the maternal abdominal skin. A uterine rupture is diagnosed and a Caesarean section confirms the diagnosis. The infant is left with significant developmental delay and physical disability requiring lifelong care .

A legal action is commenced. Nursing experts are critical of the nurse’s failure to respect the oxytocin protocol and exceeding the maximal allowable dose, and for failing to identify the significance of the change in EFM tracing after the start of the infusion. Medical experts are critical of the physician’s unclear communication with the nurse, failure to follow up on the effect of the oxytocin, failure to review the dose and rate of infusion, and not examining the patient’s abdomen when she reassessed the patient for fever. Without expert support, a settlement is paid by the CMPA, on behalf of the member physician, and by the hospital on behalf of the nurse.

Defining safety culture

A safety culture is one that demonstrates an organization-wide commitment to providing the safest possible care. A safety culture recognizes that, while mistakes do happen and outcomes are not always ideal, all healthcare providers share a common goal of providing quality care, and work collaboratively and share knowledge to achieve that goal. Individuals are encouraged to critically assess everyday situations for potential increased risk of harm to patients. Physicians and other providers learn from patient safety incidents when they do occur, and these are analyzed to prevent similar events in the future.

While the focus for quality improvement is on systems, individual physicians and other healthcare providers have responsibilities within the system and are accountable to comply with policies and procedures; practise only if healthy to do so; maintain knowledge and skills; participate in quality improvement activities; and learn from quality improvement reviews and patient safety incident analyses.

Reducing variations in care

An important aspect of healthcare system quality and safety is reducing inappropriate variations in care. Such variations can be reduced using a variety of approaches including clinical practice guidelines and checklists. As well, physicians should be aware of and follow their institution’s safety policies, such as those concerning patient handovers or hand hygiene. Hospitals may also implement care bundles to minimize variation, such as bundled interventions to prevent sepsis or central line infections, and physicians should be familiar with these, when applicable.

Physicians may, on occasion, regard such tools as being too prescriptive or lacking validation (e.g. absence of placebo-controlled double-blind trials). Some physicians may feel that checklists and policies could stifle their autonomy and judgment. To counter such perceptions, physicians and other members of the healthcare team should participate in the development of such protocols and tailor them to their specific patient population or workflow processes. Care team members should understand the intervention is intended to develop and instill safe behaviours in the workplace.

Sometimes a physician may need to override a protocol or guideline, though this should be considered only after careful assessment of the clinical circumstances. In certain circumstances, consulting with a colleague may validate the decision-making process. It is important to discuss reasonable treatment options with the patient, and to document the rationale for any deviation and the patient’s decision.

A multi-faceted approach for prevention of avoidable harm

Preventing avoidable harm requires a multi-faceted approach that addresses the systemic issues and the care delivered by individual healthcare providers.

At the provider level, clear, sufficient, and timely communication between all members of the healthcare team including patients and families is critical to healthcare safety. Varying styles of communication, different personalities, and hierarchies are some of the factors affecting communications among physicians and other healthcare providers.

Team-based training, similar to crew resource management in the aviation industry, encourages situational awareness, shared mental models for communication (whereby care team members share their perceptions of a situation), and speaking up. Tools such as handover mnemonics, the two-challenge rule,2 and techniques such as CHAT (Context, History, Assessment, Tentative plan) and CUS (Concerned, Uncomfortable, Scared) can also help improve communication and safety.

Simulations enable physicians and other healthcare providers to develop and refine their skills without compromising the safety of patients, and permit providers to gain experience with checklists and other tools that impact quality of care. Repetitive simulations with the entire team create a safe environment to learn and practise, and simulation debriefings encourage open dialogue across the team.

The bottom line

The prevention of avoidable harm requires a multi-faceted approach that involves systems thinking. Such an approach includes contributing to a just culture in which patient safety incidents are reported and analyzed to avoid recurrence, and collaboration among care providers to critically assess everyday situations for potential risk. The best possible outcomes for patients may be achieved when all care providers share a collective responsibility to deliver safe medical care.



  1. Agency for Healthcare Research and Quality, “Patient Safety Primer: Systems Approach,” 2012. Accessed on January 27, 2015 from:
  2. Two-challenge rule: A rubric for challenging others using a conversational technique that is assertive and collaborative, and which may improve the frequency and effectiveness with which healthcare providers “speak up” to others, including superiors.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.