Drifting towards death: a South African patient safety incident through an HFE Systems lens
- Authors: Agar, Sarah Leigh
- Date: 2022-10-14
- Subjects: Patients Safety measures , Medical errors Prevention , Human engineering , Medical care South Africa
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/362716 , 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. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2022
- Full Text:
- Date Issued: 2022-10-14
- Authors: Agar, Sarah Leigh
- Date: 2022-10-14
- Subjects: Patients Safety measures , Medical errors Prevention , Human engineering , Medical care South Africa
- Language: English
- Type: Academic theses , Master's theses , text
- Identifier: http://hdl.handle.net/10962/362716 , 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. , Thesis (MSc) -- Faculty of Science, Human Kinetics and Ergonomics, 2022
- Full Text:
- Date Issued: 2022-10-14
The application of human factors and ergonomics (HFE) to community-sport organisations in resource scarce contexts: a case study of grassroots football in Makana, Eastern Cape
- Authors: Bennett, Ryan
- Date: 2021
- Subjects: Makana Local Football Association (South Africa) , Human engineering , Soccer teams -- South Africa -- Makhanda -- Management , Soccer -- Management -- South Africa
- Language: English
- Type: text , Thesis , Doctoral , PhD
- Identifier: http://hdl.handle.net/10962/172412 , vital:42198 , 10.21504/10962/172412
- Description: Background: Modern Human Factors and Ergonomics (HFE) focuses on the optimisation of complex socio-technical systems and has been challenged to contribute to broader societal issues. An example is within grassroots football organisations in resource-scarce areas such as Makana, South Africa. Through embedded participatory approaches, the research problem was co-constructed: To investigate the socio-technical system of the Makana Local Football Association (LFA). Method: A useful complex system modelling tool is that of Cognitive Work Analysis (CWA), with its 5 phases used to identify constraints and affordances. Three perspectives were adopted for the application of an adapted (to suit participant characteristics) CWA to the Makana LFA: 1) how work is prescribed by the governing body SAFA, 2) how subject matter experts (SME) disclose its current functioning, and 3) how SMEs imagine it could function. Five SMEs attended 12 three-hour workshops to complete the latter two perspectives. Results: The composite work domain analysis between work as prescribed and work as disclosed identified significant mismatches between how policymakers envision the system and how SMEs report its functioning. Key differences in perspectives included the fundamental purpose of the Makana LFA, while only four of 22 functions operate within the Makana LFA. Participants also identified key affordances for the LFA such as reorientation as a community sports organisation. Discussion: Comparison between perspectives indicated four mismatches. 1) SAFA views the LFA as the foundation of the talent identification and development infrastructure of South African football. SMEs view it as a community centred organisation. 2) A lack of human capacity is evident at the community level of Makana football. 3) Funding and assets are absent at this grassroots level. 4) The LFA relies on other stakeholders, but these relationships are not formalised. Policymakers, therefore, have a lack of knowledge of the contextual challenges faced by LFA administrators. It is recommended that SAFA view the LFA as a community sport organisation, focusing on improving human capacity, increasing funding, and formalising stakeholder networks. Furthermore, conceptual models from CWA provide explicit socio-technical system redesign recommendations. Conclusion: Large mismatches between the organising body SAFA and the actual functioning of the LFA significantly hinder the effective management and running of football at a grassroots level in resource-scarce contexts in South Africa. The perspectives approach to CWA was useful in elucidating the constraints and affordances of the Makana LFA socio-technical system and informing redesign opportunities. Systems HFE methodology is therefore well placed to contribute to broader societal issues within resources scarce contexts such as football in Makana. Furthermore, the philosophical underpinnings of systems based HFE were successful in the development of sustainable participatory research within the South African grassroots football context.
- Full Text:
- Date Issued: 2021
- Authors: Bennett, Ryan
- Date: 2021
- Subjects: Makana Local Football Association (South Africa) , Human engineering , Soccer teams -- South Africa -- Makhanda -- Management , Soccer -- Management -- South Africa
- Language: English
- Type: text , Thesis , Doctoral , PhD
- Identifier: http://hdl.handle.net/10962/172412 , vital:42198 , 10.21504/10962/172412
- Description: Background: Modern Human Factors and Ergonomics (HFE) focuses on the optimisation of complex socio-technical systems and has been challenged to contribute to broader societal issues. An example is within grassroots football organisations in resource-scarce areas such as Makana, South Africa. Through embedded participatory approaches, the research problem was co-constructed: To investigate the socio-technical system of the Makana Local Football Association (LFA). Method: A useful complex system modelling tool is that of Cognitive Work Analysis (CWA), with its 5 phases used to identify constraints and affordances. Three perspectives were adopted for the application of an adapted (to suit participant characteristics) CWA to the Makana LFA: 1) how work is prescribed by the governing body SAFA, 2) how subject matter experts (SME) disclose its current functioning, and 3) how SMEs imagine it could function. Five SMEs attended 12 three-hour workshops to complete the latter two perspectives. Results: The composite work domain analysis between work as prescribed and work as disclosed identified significant mismatches between how policymakers envision the system and how SMEs report its functioning. Key differences in perspectives included the fundamental purpose of the Makana LFA, while only four of 22 functions operate within the Makana LFA. Participants also identified key affordances for the LFA such as reorientation as a community sports organisation. Discussion: Comparison between perspectives indicated four mismatches. 1) SAFA views the LFA as the foundation of the talent identification and development infrastructure of South African football. SMEs view it as a community centred organisation. 2) A lack of human capacity is evident at the community level of Makana football. 3) Funding and assets are absent at this grassroots level. 4) The LFA relies on other stakeholders, but these relationships are not formalised. Policymakers, therefore, have a lack of knowledge of the contextual challenges faced by LFA administrators. It is recommended that SAFA view the LFA as a community sport organisation, focusing on improving human capacity, increasing funding, and formalising stakeholder networks. Furthermore, conceptual models from CWA provide explicit socio-technical system redesign recommendations. Conclusion: Large mismatches between the organising body SAFA and the actual functioning of the LFA significantly hinder the effective management and running of football at a grassroots level in resource-scarce contexts in South Africa. The perspectives approach to CWA was useful in elucidating the constraints and affordances of the Makana LFA socio-technical system and informing redesign opportunities. Systems HFE methodology is therefore well placed to contribute to broader societal issues within resources scarce contexts such as football in Makana. Furthermore, the philosophical underpinnings of systems based HFE were successful in the development of sustainable participatory research within the South African grassroots football context.
- Full Text:
- Date Issued: 2021
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