LIIPS Seminar: Systemic Accident Analysis Methods – What are they and how feasible are they for healthcare incident investigation?

Date: 29 November 2017

Time: 10.30am - 12.30pm

Venue: Centre for Medicine, University of Leicester

To book: If you would like to attend please email with your name and organisation.

Please note, places are limited and will be allocated across all LIIPS partner organisations


After the release of a 3min animation, Systems Thinking – a new direction in healthcare incident investigation, there are enthusiastic responses calling for an alternative systemic method for healthcare incident investigation. At the same time, there are suggestions that Root Cause Analysis (RCA) suffers more from an implementation problem than being fundamentally flawed.

In this two hour seminar, we would like to present three systemic accident analysis methods with illustrative examples. We will discuss the utility and feasibility of the systemic analysis methods for healthcare incident investigation.

Local examples will be used including:
• insulin over prescription, details on the system thinking website
• suicide incidents using one of the methods (STAMP)
• UHL hospital pharmacies using another method (causal loop diagram)

Also covered will be how other sectors apply systemic methods for incident reporting and analysis.

The session will be interactive and feedback from workshop participants will be collected as part of impact measurement of the animation production project (sponsored by the Health Foundation).


Speaker Biography

Thomas JunDr Gyuchan Thomas Jun is Lecturer in Human Factors and Complex Systems at Loughborough Design School, Loughborough University, UK. He is a researcher, educator and design facilitator working in a broad field of human factors, engineering design and service design. He is particularly interested in integrating systems thinking, design thinking and resilience thinking into complex system/service design practices. He was trained as an engineer, but has been an interdisciplinary researcher with the intention of bridging various disciplines. He led the production of a highly praised 10 min animation on system safety, Two Contrasting Views of South Korea Ferry Accident.

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