A paradigm shift to enhance patient safety in healthcare, a resilience engineering approach: scoping review of available evidence

Risk management has a number of accident causation models that have been used for a number of years. Dr. Nancy Leveson (2002) has developed a new model of accidents using a systems approach. The new model is called Systems Theoretic Accident Modeling and Processes (STAMP). It incorporates three basic components: constraints, hierarchical levels of control, and process loops. In this model, accidents are examined in terms of why the controls that were in place did not prevent or detect the hazard(s) and why these controls were not adequate to enforcing the system safety constraints. A STAMP accident analysis is presented and its usefulness in evaluating system safety is compared to more traditional risk models. STAMP is applied to a case study in the oil and gas industry to demonstrate both practicality and validity of the model. The model successfully identified both direct and indirect violations against existing safety constraints that resulted in the accident at each level of the organization.