A three-dimensional model of error and safety in surgical health care microsystems. Rationale, development and initial testing

We have developed a new, simple, model of safety in healthcare systems, based on analysis of real problems seen in surgical systems, in which influences on risk at the "microsystem" level are described in terms of only 3 dimensions - technology, system and culture. We used definitions of these terms which are similar or identical to those used elsewhere in the safety literature, and utilised a set of formal empirical and deductive processes to derive the model. The "3D" model assumes that new risks arise in an unpredictable stochastic manner, and that the three defined dimensions are interactive, in an unconstrained fashion. We illustrated testing of the model, using analysis of a small number of incidents in a surgical environment for which we had detailed prospective observational data.The model appeared to provide useful explanation and categorisation of real events. We made predictions based on the model, which are experimentally verifiable, and propose further work to test and refine it.We suggest that, if calibrated by application to a large incident dataset, the 3D model could form the basis for a quantitative statistical method for estimating risk at microsystem levels in many acute healthcare settings."Essentially, all models are wrong, but some are useful"George AP BoxIt is only in the last 2 decades that it has become acceptable to admit that modern healthcare causes harm to patients. Early writers who drew attention to this, like Ivan Ilich[1], were dismissed as dystopian, whilst others, who raised the problems of healthcare harm after experiencing personal tragedy, were clearly not neutral observers. The medical and nursing professions have had difficulty in looking squarely at this issue, since our professional cultures contain a fundamental assumption of absolute commitment to selfless service, and the most demanding standards of performance. This mindset made it difficult to acknowledge the problem of patient harm, but eventually careful retrospectiv