Translating Systems Thinking into Practice: A Guide to Developing Incident Reporting Systems

Systems thinking tells us that human error, violations and technology failures result from poorly designed and managed work systems. To help us understand and prevent injuries and incidents, incident reporting systems must be capable of collecting data on contributory factors from across the overall work system, in addition to factors relating to the immediate context of the event (e.g. front-line workers, environment, and equipment).

This book describes how to design a practical, usable incident reporting system based on this approach. The book contains all the information needed to effectively design and implement a new incident reporting system underpinned by systems thinking. It also provides guidance on how to evaluate and improve existing incident reporting systems so they are practical for users, collect good quality data, and reflect the principles of systems thinking.