Collaborative Safety Research

Kelly Knutson's thesis at Lund University explores the application of systems thinking, specifically the AcciMap approach, to maltreatment investigations in licensed facilities. The study focuses on how this approach can support investigators in understanding complex systemic interactions and identify systemic influences to prevent future incidents. By facilitating AcciMap sessions with licensing investigators, the study demonstrates that this method helps move away from blame, provides a comprehensive view of incidents, and supports key aspects of investigative work. The findings suggest that systems thinking can offer valuable insights and improvements in handling maltreatment cases, differing from traditional linear investigation models.