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Quality improvement

Learning from adverse events (accidents in Québec)

Systems thinking

Graphic of Swiss Cheese ModelThe traditional response to an adverse event (accident in Québec) has focused on identifying and blaming the providers who had the last contact with the patient, resulting in calls for greater vigilance, better training, and sometimes professional sanctions or firings.

However, the same problem may recur in the future unless a real attempt is made to understand the circumstances and context for the decisions and actions at the time of the event.

By contrast, systems theory in patient safety emphasizes that focusing on the system rather than on the individual will help prevent more adverse events.

Patient safety experts argue that acting on the recommendations from a quality improvement review of the system of care is one of the more effective approaches to improving patient safety in a hospital or healthcare institution.

Similar adverse events can be prevented over time by strengthening system protections, which will benefit future patients.

Providers are still responsible for the quality of their work within the system. The objective is to find the right balance between improving healthcare and helping all providers prevent similar events in the future, while fairly addressing any issues of individual provider performance and accountability. This more balanced approach is often referred to as a "just culture of patient safety."

For more information see systems thinking.