The Art Of Thinking In Systems: Improve Your Logic, Think More Critically, And Use Proven Systems To Solve Your Problems Strategic Planning For Everyday Life pdfdrive com

An example of systems thinking at its finest
Every system that involves human beings is bound to include errors, as there is
no such thing as a perfect person who never makes mistakes. The healthcare
system is no different. The National Institute of Health issued a report “To Err is
Human” that looks into errors in the field of healthcare. The following findings
were a part of this report.
The healthcare system has always studied why medical professionals made
mistakes. Until the last few decades, the focus was on the individual who made
the error. Blame was assigned to the doctor or nurse who made the mistake, and
a punishment was issued in the hopes that it might prevent errors from occurring
in the future.
More recently, there was a shift in thinking when it came to analyzing medical

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mistakes. Instead of only looking at an individual as being solely responsible, the
healthcare system found that evaluating the failures in the systems that led to the
error was much more helpful in preventing similar errors in the future. Assigning
blame was not given as much importance as finding ways to improve systems
and make proactive decisions to prevent potentially life threatening errors from
happening again.
When an error was made, everything in the system was analyzed from the way
medication was labeled, to whether the staff was overworked with too many
patients or hours on their schedule, to whether the order issued by the doctor was
able to be clearly and easily understood, and many more influencing factors. It
was often discovered that an error had happened well in advance of when it
actually manifested itself.
The healthcare system had confidence that its employees wanted to help the
patient above all else, but also understood that they were human, so mistakes
would be made. They made the decision to encourage their employees to be
honest about reporting errors by creating a safer and more blame-free
environment in which they could do so. They believed that learning from
mistakes and improving systems was more important than issuing punishments.
As a result, systems thinking has helped to make things like systems for
reporting errors, checklists that must be followed for procedures, and guidelines
for patient safety standard practice in healthcare.
Systems thinking is a powerful way of thinking that has great potential to impact
our lives in so many ways, if we are open to all of the benefits and lessons it has
to offer.

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