Thinking In Systems

This quarter I’m taking a class on Safety in Healthcare, and a (if not THE) prevailing theme throughout the first five weeks has been a the need to focus on systems.

When it comes to medical errors, the old (and unfortunately still existent) way of thinking is to place blame on the individual clinician – whether it be the nurse who gave a patient the wrong medication or the doctor who misdiagnosed a patient and missed the critical opportunity to provide effective treatment. This approach gives into the instinctual need to place blame on someone, and is in line with the litigious nature of society (in turn contributing to the rising cost of medical malpractice, a factor in the extremely high medical costs overall).

What this person-focused approach does not consider, however, are the broken systems that make it far too easy for clinicians to make mistakes. For example, medications that look similar or have similar names can be easily mixed up by a nurse who is busy looking after multiple patients, and a physician who has been up all night on call might not have the cognitive acuity needed to make the right diagnosis. While there were actions that led to these errors, the errors only occurred because of the multiple failures of the system.

Other industries, such as nuclear power and aviation, have embraced the systems approach, and have seen a resulting decline in errors. Healthcare is following suit, albeit slowly. New ways of preventing errors within care delivery systems are being developed, supported by voluntary reporting systems that focus on near-misses and system problems.

Thinking in systems is useful far beyond these industries. The questions asked in a systems view is “Are we doing all that we can?” Whether that be to achieve industry goals such as preventing nuclear disasters, lowering aviation accidents and mortalities, and improving patient safety, or to achieve other social goals. Are we doing all that we can to create a health population of productive citizens?

In many ways, we are not. Take, for example, one of the millions of young African American males incarcerated for drug offenses.  The prevailing view is that these men are “bad” or “lazy” and have ultimately made a choice that deserves some severe punishment.  This is the individualist view.  The systems view might recognize that a young man who grows up in poverty without a father who wants to care for a disabled or elderly mother might not be able to graduate from his poorly run inner city high school, and therefore won’t qualify for a job that pays more than minimum wage or might not be able to find a job at all, and may feel that they only way to make ends meet and fulfill his duty as a son is to sell drugs for cash, a far more lucrative career than most of those available to those without high school diplomas or college degrees.  This view is more difficult to think about, and makes it harder to place blame, but ultimately shows how many lost opportunities there were to prevent the boy from failing and from feeling coerced into a criminal activity. We can look at social ills in society and think that they are creations of circumstance, or we can think of them as the flaws of individuals; too often we choose the latter.  But until we learn to think in systems, we will continue letting too many failures happen.


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