| Document
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Author Victoria E. Wills, Andrew Seaton |
| Abstract A system safety review to assess the resilience in Trauma and Orthopaedic (T&O) theatres was conducted in response to a number of Never Events. The imminent publication of the Patient Safety Incident Response Framework (PSIRF) paved the way for an alternative to traditional serious incident investigation, proposing a systems-based approach and enabling subsequent improvements to be based on ‘work as done’, rather than ‘work as imagined’. Analysis identified opportunities for interventions that built system resilience, which were developed and tested by front line staff as part of a Quality Improvement (QI) collaborative. The approach demonstrated a practical application of the integration of systems theory, patient safety, resilience engineering and quality improvement approaches. |
