From Cheese to STEW: incorporating a systems’ approach to critical incident analysis

  • Sarah Carriere BC Patient Safety & Quality Council, Canada


The Canadian Incident Analysis Framework (CPSI, 2012) supports healthcare providers that are involved, manage, analyse and learn from patient safety incidents, with the goal of increasing the effectiveness of incident analysis and enhancing the safety and quality of patient care. Although the framework incorporates multiple methods to analyse incidents, the identification of contributing factors is solely based on a linear and root cause understanding of what, how and why an event happened; the Swiss Cheese Model acts as a fundamental concept that supports the framework’s incident management pathway. An alternative and practical approach to support critical incident analysis and supplement the CPSI framework is STEW: Systems Thinking for Everyday Work (NHS, 2018). These discussion cards frame team conversations and support systematic group discussion in order to analyse patient safety incidents by understanding the current system (work-as-imagined to work-as-done), understand why decisions made sense at the time, explore performance variability, analyse interactions and flow, and identify improvement priorities.

At our hospital and after a recent medication error, we applied the 6 principles of STEW to explore and better understand the medication event – with the premise that things normally work and go right with no unintended outcomes – in order to identify opportunities for improvement and sustain resilience. A team that brought multiple perspectives analysed the incident, identified short and long term change ideas into the current work system, and continue to monitor and evaluate change. Understanding performance variability allowed the team to identify areas to increase performance and staff to feel supported, resilient and valued. With a value for restorative just culture, STEW gave means to switch from a reactive find-and-fix mode, to a proactive patient safety management and better understanding of everyday work performance and flexibility.