The Perfect Storm: How System Failures Compromise Patient Safety

This interactive session will explore a real-world patient safety event involving the dislodgement of an endotracheal (ETT) tube examined through the lens of human factors and systems thinking. Rather than attributing the error to individual actions, we will analyze the multiple failures across various subsystems that contributed to the event. Participants will engage in an open, interactive discussion aimed at identifying key breakdowns between different subsystems, such as communication, workflow, equipment design, and organizational processes that led to the adverse outcome.
Adopting a structured, blame-free approach, we will work through the investigation process to uncover root causes and systemic vulnerabilities. This session emphasizes the importance of fostering a culture of learning and safety rather than punishment, ensuring that insights from the event drive meaningful improvements. By applying human factors principles, participants will explore strategies to prevent similar events, enhance teamwork, and design safer systems that support both patients and clinical care providers.