- Title
- Drifting towards death: a South African patient safety incident through an HFE Systems lens
- Creator
- Agar, Sarah Leigh
- ThesisAdvisor
- Todd, Andrew I
- ThesisAdvisor
- Davy, Jonathan Patrick
- Subject
- Patients Safety measures
- Subject
- Medical errors Prevention
- Subject
- Human engineering
- Subject
- Medical care South Africa
- Date
- 2022-10-14
- Type
- Academic theses
- Type
- Master's theses
- Type
- text
- Identifier
- http://hdl.handle.net/10962/362716
- Identifier
- vital:65356
- Description
- Patient Safety Incidents (PSI) are a frequent occurrence within the South African public healthcare system wherein a patient is unnecessarily maimed, harmed, killed, or put through significant trauma, emotional or physical. These incidents have a significant impact on the performance of the system and the well-being of individuals involved. Often PSI are the result of multiple system failings that provide the necessary preconditions for the PSI to occur. Thus, to provide appropriate patient safety recommendations to address and aid in the prevention of future PSI it is necessary to apply a systems approach to PSI analysis. A systems approach supports a ‘bigger picture’ view of an incident which includes looking beyond the immediate causes of a PSI and taking the different levels of the healthcare system into consideration during incident analysis. Human Factors and Ergonomics (HFE) is at its core a systems discipline and has been successfully applied to multiple fields including healthcare. HFE offers multiple incident analysis tools grounded in systems theory. The Life Esidimeni incident, a PSI that resulted in the death of 144 MHCU, is the biggest PSI in recent South African history and is therefore an important potential case study for the application of HFE systems tools within the South African healthcare context (an area that is lacking in existing literature). The objectives of this research were to (i) Systematically uncover the causal factors that led to the outcome of the of the Life Esidimeni incident; (ii) Identify critical faults, and gaps within the healthcare system that led to the Life Esidimeni PSI; and (iii) Provide proactive recommendations for future prevention of PSI. To fulfil these objectives a descriptive case study research method design was adopted using a qualitative systems-based tool, AcciMap. The application of AcciMap to Life Esidimeni enabled both the sharp end and blunt end causal factors that contributed to the outcome of the incident to be identified. Importantly this provided insight into the critical faults and gaps of the South African public healthcare system. The results of the AcciMap indicated that there were four main broad systemic faults in the system. These broad areas were categorized as key themes, which include: (i) competency, (ii) safeguards, (iii) time pressures, and (iv) vertical integration. From these key themes recommendations aimed at addressing the critical faults and gaps in the system and preventing future PSI were made.
- Description
- Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2022
- Format
- computer, online resource, application/pdf, 1 online resource (158 pages), pdf
- Publisher
- Rhodes University, Faculty of Science, Human Kinetics and Ergonomics
- Language
- English
- Rights
- Agar, Sarah Leigh
- Rights
- Use of this resource is governed by the terms and conditions of the Creative Commons "Attribution-NonCommercial-ShareAlike" License (http://creativecommons.org/licenses/by-nc-sa/2.0/)
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | SOURCE1 | AGAR-MSC-TR22-152.pdf | 1 MB | Adobe Acrobat PDF | View Details Download |