Figure 1.

Illustration of how a skilled practitioner might combine their insider knowledge with a more analytical outsider perspective to examine how the external and internal environment, the organisation of work and the different groups of people who conduct tasks, using the tools and technologies available to them, all result in the actual processes and outcomes of care. In this diagram, the inner arrow represents the main care activities, these are often defined on a medical round, as here when baby Bahati was started on a new course of antibiotics and oxygen (shift 1). The Newborn Unit (NBU) team uses tools and technologies (eg, patient monitoring charts, pulse oximeters, weighing scales) and is involved in team-based activities (all encompassed in the blue cylinder). Wider organisational activities also continue (encompassed by the brown cylinder) such as the three shift changeovers. Some of these activities (eg, handing over or ordering supplies) require engagement with other hospital departments or teams. Other activities are less predictable but may strongly influence practice (eg, unexpected staff absence or dealing with a distressed parent). All of this activity takes place within a wider environment (represented by the black cylinder), which can influence NBU care (eg, inadequate supply of medicines or failure to recruit new staff). We highlight using red text how multiple contributing factors that affect baby Bahati’s care (panel 2) combine to produce important process failures and subsequently harms.