When investigations fall short: Why incident reviews need a systems-lens (BMJ analysis)
A new study published in BMJ Quality & Safety highlights a persistent gap in how healthcare organisations investigate safety incidents. Despite operating in highly complex systems, many reviews still default to linear, individual-centred explanations rather than exploring the broader sociotechnical factors at play.
For hospitals, aged-care services and multidisciplinary networks navigating staffing pressures, reforms and digital transformation, the findings are a timely reminder: effective investigation must mirror system complexity.
1. Healthcare incidents are rarely linear — investigations should reflect that
The study shows most investigations still focus on “what someone did” instead of “what the system enabled.”
In environments shaped by staffing mix, shift timing, digital tools, handover processes and regulatory requirements, incidents typically arise from multiple interacting factors, not single errors.
Implication: Teams should routinely examine workload, communication flow, technology usability, training, environmental constraints and process design — not just frontline actions.
2. Five elements that strengthen investigations
The authors highlight five areas where organisations can lift investigation quality:
- Sociotechnical analysis: considering human, organisational and technology factors together.
- Richer data capture: gathering meaningful context, not only forms and timelines.
- Independence: structurally separating investigators from the area involved.
- Professionalised skills: building expertise in systems thinking and human factors.
- Data aggregation: analysing trends, not isolated events.
Why it matters: Workforce and rostering teams in particular can uncover deeper insights when they connect incident data with patterns in overtime, fatigue, substitution rates, staffing mix and shift variability.
3. The risk of reverting to blame instead of learning
Despite good intentions, many reviews still conclude with individual error, training reminders or policy restatements.
The research found fewer than two-thirds of respondents believed their investigations actually prevented recurrence.
This is because narrowly framed investigations often miss the structural contributors — system design, workload pressures, unclear processes, technology friction or cultural norms.
Bottom line: Blame might close a case, but only system-level learning reduces future risk.
4. What this means for aged-care and healthcare organisations
For leaders responsible for safety, compliance, rostering and workforce strategy, the study reinforces four priorities:
1. Build investigation-ready systems
Ensure metadata, staffing patterns, skill mix, fatigue indicators and handover records are easily retrievable.
2. Review incidents thematically
Combine near-misses, shifts and time-of-day patterns to reveal hidden risks.
3. Upskill investigation teams
Human-factors skills are now essential, not optional.
4. Create independent learning loops
Separate investigation from operational ownership and ensure insights flow back to frontline teams.
These shifts not only improve safety outcomes — they strengthen workforce wellbeing, transparency and organisational resilience.
Closing: Investigations as a lever for safer, more sustainable care
The research is clear: high-quality investigations are not about finding fault — they’re about understanding complex systems well enough to prevent harm.
For organisations navigating reforms, staffing shortages and digital transformation, adopting a systems lens is no longer optional. It’s essential for building a safer, more sustainable workforce.
RLDatix continues to support providers across APAC to elevate their safety, workforce and governance practices with connected, system-aware tools that strengthen learning and resilience.
Resources:
To explore the full research findings, you can access the BMJ Quality & Safety article below. The article offers richer detail on the study’s methods, themes and recommendations.
Leading the Way with RLDatix
At RLDatix, we believe lasting transformation in healthcare requires more than compliance; it demands connected systems that embed safety, governance, and continuous improvement into everyday practice. Our healthcare-first solutions support providers across Australia in building resilient operations, empowering their workforce, and delivering safer, high-quality care in line with national priorities.
