System-level safety hazards of a generic health care and welfare system on national level
Version 2
Introduction
This is an updated version and continuation of this text that I published here in October 2022: Suggested system-level hazards for health care, first draft
This text may be seen as the next stage of the top-down safety analysis of this subject, which is not a complete safety analysis, it is mainly a start which is made for educational purposes. In the first draft, a generic health care system was described from a safety point of view via system hazards, but also including some parts of a welfare system as well as work safety for the personnel working in these systems.
In this second draft the analyzed system is described in a little more detail, and the analysis also comprises how flaws in a general welfare system may contribute to disease, injury or death. This extended system definition is used for the top level because there are important interactions between the health care system and other parts of the welfare system, and this extended system gives a basis for a more complete analysis.
My intention is to go more into detail later on parts of this quite comprehensive scope, and also update the top level described in this text. System level hazards may be defined in different ways, there is no absolute truth on how they should be formulated, but some rules should be followed.
The concept of top hazards or system-level hazards is used when making safety analyses using FTA (Fault Tree Analysis), and STPA (System-Theoretic Process Analysis). See the introduction chapter in the previous version of this text for an explanation of the hazard concept. STPA is described here: STPA Handbook and FTA is described here Guide to safety analysis for accident prevention
I want to thank Lawrence Wong at Massachusetts Institute of Technology and Elizabeth W Baker at Virginia Commonwealth University for very helpful discussion and comments on my first draft.
System definition of a generic national health care and welfare system
This analysis comprises a generic health care system and applicable parts of a welfare system on national level, not only patient safety in the traditional sense. How could patients as well as (some) healthy people get harmed in the welfare system, and related to flaws in the system?
The generic health and welfare system in this analysis consists of the following parts:
A national health care system as a whole
Infection control on national and local level
Applicable parts of a national generic welfare system that has close connections to health care and the needs of people that are sick or that has disabilities, the elderly etc.
Work safety for all personnel and officials working in this system
Other parts of a generic welfare system that may play a role in preventing people to get sick or harmed in other ways.
Which exact parts of a welfare system that really are applicable will be clarified if and when the analysis is continued on deeper levels.
Safety hazards connected to transportation, chemicals etc. are not covered in this analysis, only what is included in welfare.
Note that there are different kinds of welfare systems, this is meant to be a generic analysis of possible hazards, if and how those are prevented is not handled here. This is a basis for a discussion about that, and a basis for more specific and detailed analyses.
Suggestion of system-level hazards for a national health care and welfare system seen as a whole
Note that these hazards are chosen as events, not as conditions. Either could be used, but must be done consistently.
These hazards are defined so that they should include all kinds of possible hazards/harms in the system, and they are chosen so that the total number of them will be just a few.
A person that is sick, injured, disabled and/or old is harmed by not getting help and care from health care and other welfare systems that would be possible, or by getting help and care too late.
A person that is sick, injured, disabled and/or old is harmed while getting help and care from health care and social care.
A healthy person is harmed when receiving some kind of medical intervention with hazardous side-effects, for other reasons than health problems, e g for beauty reasons, or donation of organs for transplants.
A person that works in a welfare system giving support and/or care to people that are sick, injured, disabled and/or old, is harmed related to work.
A person gets a serious infection in society, that is connected to lacking or inadequate infection control, according to science, law and risk acceptance criteria, during a pandemic or otherwise.
A healthy person is getting sick related to poverty, unemployment, homelessness etc combined with lacking support from society.
Discussion and examples of different causes of the suggested system-level hazards
The listed sub-hazards and causes mentioned below are examples, the lists are NOT intended to be complete.
System hazard #1: A person that is sick, injured, disabled and/or old is harmed by not getting help and care from health care and other welfare systems that would be possible, or by getting help and care too late.
Examples of sub-hazards/causes:
The patient does not understand the need for help and care and does not ask for it
The patient is scared for some reason and does not want to ask for help and care
The patient is not able to ask for help and care, and no one else helps the patient to do so
The patient can´t afford needed help and care, which delays asking for it and/or delays being able to pay for it.
The availability of help and care is too low
A patient gets ill or injured far away from available health care
A patient may be diagnosed correctly and in time, and prescribed correct treatment, but is not given treatment in time, e g due to low availability of surgery or medications
System Hazard #2: A person that is sick, injured, disabled and/or old is harmed while getting help and care from health care and social care.
Examples of sub-hazards/causes for a patient in health care:
A patient gets an incorrect diagnosis
A patient does not get a diagnosis
A patient with a correct diagnosis does not get correct treatment
A patient gets treatment given in an incorrect way, but diagnosis and treatment are correct.
A patient gets treatment intended for someone else
A patient gets an infection or other hospital related harm(s)
Flawed supervision of a patient with correct diagnosis and treatment; the state of changed seriousness of a patient´s state of health is missed or misjudged.
Some kind of nosocomial infection or infestation; bacterial and viral infections, or infestations with e g lice or scabies.
Injuries not related to the medical treatment, e g falls, trauma, pressure ulcers
Harm due to lacking security, like fire or crime.
The patient is harmed during investigation procedures, e g x-ray examinations, endoscopy, biopsies, blood sampling etc.
Examples of sub-hazards/causes for a patient in health care, palliative care or retirement/care home:
A patient is misjudged as dying and therefore not getting correct health care.
A patient is misjudged as not dying and is given health care instead of palliative care.
In the first case, a patient may actually have a condition that may be treated, but is misjudged as dying and therefore gets palliative care instead of treatment. I believe this hazard is more often related to elderly patients, less often for e g cancer patients.
In the second case, a dying patient may get treatment that will do more harm than good, the patient may e g be sent to emergency care instead of getting a chance to die in peace at home, at a care home or hospice.
Both these are serious hazards related to the sometimes very difficult task to understand when a patient is beyond cure and treatment, and when a patient is dying.
Example of a sub-hazard related to welfare systems:
A patient that is unable to work for a living, due to disease or injury, get further injured or sicker due to lack of money and/or lacking support from the society/state.
Example: If a person that has a deep depression and is too sick to work, also loses the economic support from the society, that might cause extreme stress if that person does not have enough for a living. There is a risk for suicide.
System Hazard #3: A healthy person is harmed when receiving some kind of medical intervention with hazardous side-effects, for other reasons than health problems, e g for beauty reasons, or donation of organs for transplants.
When treatment and interventions are given in health care, normally they are given because the risks are considered higher if not given. But for a healthy person, interventions will almost always cause higher risks, and therefore the safety is even more important. But the sub-hazards are in general the same as for System Hazard #2
System hazard #4: A person that works in a welfare system giving support and/or care to people that are sick, injured, disabled and/or old, is harmed related to work.
Examples of sub-hazards:
Some kind of infection or infestation; bacterial and viral infections, or infestations with e g lice or scabies.
Harm due to lacking security, like fire or crime.
Threats from clients.
Work accidents, injuries and diseases other than mentioned above
System Hazard #5: A person gets a serious infection in society, that is connected to lacking or inadequate infection control, according to science, law and risk acceptance criteria, during a pandemic or otherwise.
Without risk acceptance criteria, it is in many cases not possible to state what is adequate infection control, and those criteria are a matter of politics.
Examples of sub-hazards to be added later.
System Hazard #6: A healthy person is getting sick related to poverty, unemployment, homelessness etc. combined with lacking support from society.
What hazards may lead to people getting harmed because they are outside the reach and/or scope of the welfare system?
Examples of sub-hazards to be added later.