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Systems Approach

Industry has traditionally treated quality problems and errors as failings on the part of individual providers, perhaps reflecting inadequate knowledge or skill levels. The "systems approach," by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems (eg, expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations). Rather than focusing corrective efforts on reprimanding individuals or pursuing remedial education, the systems approach seeks to identify situations or factors likely to give rise to human error and implement "systems changes" that will reduce their occurrence or minimize their impact on workers. This view holds that efforts to catch human errors before they occur or block them from causing harm will ultimately be more fruitful than ones that seek to somehow create flawless providers.

This "systems focus" includes paying attention to human factors engineering (or ergonomics), including the design of protocols, schedules, and other factors that are routinely addressed in other high-risk industries but have traditionally been ignored .


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