Accidents happen. That statement has become so true for most of us, we rarely—if ever–examine what it means and implies.

In response to “accidents happen”, safety professionals have developed ways to investigate the root cause of accidents. The thought is: If the incident root cause is determined, we can avoid repetition and perhaps some accidents altogether.

The two current paradigms for root cause are:

  • Sequential Accident Model: This paradigm assumes that any accident is the result of a chain of cause and effect events. In practice, this is the paradigm most often used for incident investigation with the promise that once knowing the root cause, alterations will happen to make accidents less probable. However, this model may be inadequate when we are working in higher-order socio-technical systems like hospitals or medical schools. The sequential accident model may leave useful and necessary information untouched or, better said, unseen.
  • Epidemiological Accident Model: The epidemiological model uses the spread of disease as a metaphor for cause in accident determination and prevention. It is broader-based and takes into account factors not usually considered by the sequential model like performance variations, atmospheric conditions, hidden or latent conditions and social or mechanical barriers to functioning. While more comprehensive, it remains a cause and effect model like sequential.

Healthcare Innovation: A third model has recently emerged from the world of Health, Safety and Environment. Sidney Dekker, a professor of human factors and system safety at Lund University, Sweden has offered an innovative paradigm. Dekker states that all-cause and effect models stop short of a true view of an accident. His model argues that a cause-and-effect incident investigation never takes into account how the circumstances occurred to the operator at the moment of the accident. His new model stresses context –or how the incident occurred–as phenomena that organized the actions of the incident.

If accidents are related to how the circumstances occurred at the time and not to a “bad apple” in the process, procedure or the human operator, we are on the edge of a breakthrough and would be a healthcare innovation. A contextual model could be particularly important in healthcare.

At Insigniam we’ve researched leadership and context for years. As a result, we think that:

  • Context is decisive in most, if not all, human activities.
  • Performance is a function of how the world occurs. 1
  • Context is malleable; not fixed like cause and effect phenomena presuppose.
  • Any powerful context for safety organizing behavior today within a human system will diminish in power over time.

During our years of work in health care, we’ve never met a medical professional who opposed the context of “do no harm”. We think safe practice is inherent to the medical profession.

If we are right in our assumptions and a contextual model for safety is correct, the context for safety in medical practice only needs to be recovered or revived from time to time. Medical incident rates, lost time accidents, and institutional-based disease rates will reflect the current context.


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