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Systemic analysis of a large-scale organisation failure in UK healthcare

Jun, Gyuchan Thomas and Canham, Aneurin (2019) Systemic analysis of a large-scale organisation failure in UK healthcare. In: Proceedings of Relating Systems Thinking and Design RSD8 Symposium, Oct 13-15 2019, Chicago, USA.


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Simple linear approach prevalent in the majority of healthcare incident analyses has been the target of criticism and is not felt to be effective in complex systems, such as healthcare. STAMP (System Theoretic Accident Modelling and Process) is felt to be a promising method for the improvement of healthcare incident analysis. This study, therefore, aims to explore the applicability pf STAMP in healthcare through the case study of the STAMP application to the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005- 2009. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP. Healthcare stakeholders were generally positive about the utility of STAMP in providing a system view and guiding consideration of interactions between system components. However, many felt it to be complicated method that would specialist expertise to apply. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare.

Item Type: Conference/Workshop Item (Paper)
Uncontrolled Keywords: Patient Safety Incident Investigation, STAMP and CAST
Divisions: Faculty of Design
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Date Deposited: 04 Mar 2021 18:33
Last Modified: 20 Dec 2021 16:06
URI: https://openresearch.ocadu.ca/id/eprint/3200

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