Systems thinking comes to life during ECRI’s immersive demonstration at IHI Forum

Attendees gain new understanding of how to spot risks hiding in plain sight

At this year’s Institute for Healthcare Improvement (IHI) Forum, ECRI experts delivered an innovative session that broke the mold by providing a behind-the-scenes look at how hidden safety hazards exist in real clinical environments.

“Behind the Bedside: A Live, Interactive Systems-Thinking Demonstration” invited attendees into a simulated hospital room where a seemingly routine clinical situation revealed deeper breakdowns across the healthcare work system. As nurses navigated shift change and the handoff of a patient at high risk for falls, they faced multiple barriers to safe care delivery. Issues that set the stage for risk included a cluttered and poorly configured patient room, alarm fatigue, facility and technology interruptions, missed opportunities during handoff communication, and conflicting organizational policies.

Following the clinical scenario, ECRI guided attendees through a structured debrief that identified limitations and problems across six key system components and presented strategies to address them. Participants engaged in the process by identifying challenges and safety signals in real time. An ECRI human factors engineer highlighted subtle but significant system flaws that are often accepted in daily practice.

The session was led by Kristen Crandall, MSN, RN, CPN, ECRI Associate Director, Total Systems Safety, Vicki Lewis, PhD, Senior Manager of Human Factors Engineering, and Krista McGorrian, Senior Global Marketing Manager. Tiffani Dusang, MSN, RN, CPPS, AFN-BC, NEA-BC, Vice President of Patient Safety and Risk Management for Harris Health, joined the ECRI team in the simulation and shared reflections on her experience partnering with ECRI.

“Watching the struggle to provide safe care happen right in front of you makes it clear that safety events are not caused by individual failings,” says Crandall. “Many attendees expressed how relatable the simulation was and how looking at the challenges comprehensively facilitates more effective redesign and improvement efforts. Afterward, one noted that it was ‘the most succinct and clear explanation of systems thinking in healthcare’ they had ever received.”

Systems-Thinking Resources

ECRI offers the following free articles and tools to help organizations apply systems-thinking principles that strengthen safety, resilience, and reliability in their own care settings:

• Healthcare Is a System (20-minute animated video)
• Enhancing Patient Safety through Systems Thinking in Healthcare (article)
• Think Like a Human Factors Engineer: Five Principles for Healthcare Leaders (article)
• Incident Identification and Notifications in Aging Services: A Systems-Thinking Approach (white paper)
• Total Systems Safety Approach to Hazard Vulnerability Assessment (white paper)
• Leader Rounding Tool  (helps surface safety signals and initiate follow-up)
• How ECRI helped one health system save lives by reducing sepsis mortality (impact study)