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Systems


Systems thinking for safe care

What is "systems thinking" (Page 1 of 2)


Complex highway system
  • an organized approach for improving care
  • focusing on the system, rather than on the individual, prevents more adverse events (accidents in Québec)
  • individuals have responsibility in the system

The Canadian health delivery system includes policies, processes, and infrastructure. An ideal system is designed to prevent harm and, when it occurs, to learn from adverse events to prevent reoccurrences.

The following animation compares healthcare delivery to a house of cards. Click through the animation to understand systems thinking in healthcare and how failures in the processes of care can lead to harm to patients.
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  • Systems thinking and patient harm

    A house of cards is made by stacking playing cards on top of each other.

  • The foundation for safe patient care is based on multiple components, including: funding, organizational just culture of safety, leadership, and adequate clinical resources.

  • Sometimes just the removal of one card results in the collapse of the entire structure, but usually several need to be removed for this to happen.

  • Patient safety

    Similarly in patient safety, it is usually the failure of several components of care that results in harm to a patient. This is why quality improvement initiatives to strengthen all of the components of care are so important.

Failures of the system may occur because of such factors as:

  • inadequate resources
  • unexpected technical or equipment failures
  • lack of communication across teams