A Systems Approach to Analyzing and Preventing Hospital Adverse Events
Objective: This study aimed to demonstrate the use of a systems theory-based accident analysis technique in health care applications as a more powerful alternative to the chain-of-event accident models currently underpinning root cause analysis methods. Method: A new accident analysis technique,...
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| Format: | Article |
| Language: | en_US |
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Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins
2018
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| Online Access: | http://hdl.handle.net/1721.1/115366 https://orcid.org/0000-0001-6294-8890 |
| _version_ | 1826199182249033728 |
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| author | Samost, Aubrey Dekker, Sidney Finkelstein, Stan Raman, Jai Leveson, Nancy G |
| author2 | Massachusetts Institute of Technology. Department of Aeronautics and Astronautics |
| author_facet | Massachusetts Institute of Technology. Department of Aeronautics and Astronautics Samost, Aubrey Dekker, Sidney Finkelstein, Stan Raman, Jai Leveson, Nancy G |
| author_sort | Samost, Aubrey |
| collection | MIT |
| description | Objective: This study aimed to demonstrate the use of a systems theory-based accident analysis technique in health care applications as a more powerful alternative to the chain-of-event accident models currently underpinning root cause analysis methods.
Method: A new accident analysis technique, CAST [Causal Analysis based on Systems Theory], is described and illustrated on a set of adverse cardiovascular surgery events at a large medical center. The lessons that can be learned from the analysis are compared with those that can be derived from the typical root cause analysis techniques used today.
Results: The analysis of the 30 cardiovascular surgery adverse events using CAST revealed the reasons behind unsafe individual behavior, which were related to the design of the system involved and not negligence or incompetence on the part of individuals. With the use of the system-theoretic analysis results, recommendations can be generated to change the context in which decisions are made and thus improve decision making and reduce the risk of an accident.
Conclusions: The use of a systems-theoretic accident analysis technique can assist in identifying causal factors at all levels of the system without simply assigning blame to either the frontline clinicians or technicians involved. Identification of these causal factors in accidents will help health care systems learn from mistakes and design system-level changes to prevent them in the future. |
| first_indexed | 2024-09-23T11:16:02Z |
| format | Article |
| id | mit-1721.1/115366 |
| institution | Massachusetts Institute of Technology |
| language | en_US |
| last_indexed | 2024-09-23T11:16:02Z |
| publishDate | 2018 |
| publisher | Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins |
| record_format | dspace |
| spelling | mit-1721.1/1153662022-09-27T18:18:07Z A Systems Approach to Analyzing and Preventing Hospital Adverse Events Samost, Aubrey Dekker, Sidney Finkelstein, Stan Raman, Jai Leveson, Nancy G Massachusetts Institute of Technology. Department of Aeronautics and Astronautics Leveson, Nancy G. Leveson, Nancy G Objective: This study aimed to demonstrate the use of a systems theory-based accident analysis technique in health care applications as a more powerful alternative to the chain-of-event accident models currently underpinning root cause analysis methods. Method: A new accident analysis technique, CAST [Causal Analysis based on Systems Theory], is described and illustrated on a set of adverse cardiovascular surgery events at a large medical center. The lessons that can be learned from the analysis are compared with those that can be derived from the typical root cause analysis techniques used today. Results: The analysis of the 30 cardiovascular surgery adverse events using CAST revealed the reasons behind unsafe individual behavior, which were related to the design of the system involved and not negligence or incompetence on the part of individuals. With the use of the system-theoretic analysis results, recommendations can be generated to change the context in which decisions are made and thus improve decision making and reduce the risk of an accident. Conclusions: The use of a systems-theoretic accident analysis technique can assist in identifying causal factors at all levels of the system without simply assigning blame to either the frontline clinicians or technicians involved. Identification of these causal factors in accidents will help health care systems learn from mistakes and design system-level changes to prevent them in the future. 2018-05-14T18:59:04Z 2018-05-14T18:59:04Z 2016-01 Article http://purl.org/eprint/type/JournalArticle 1549-8417 http://hdl.handle.net/1721.1/115366 Leveson, Nancy et al. “A Systems Approach to Analyzing and Preventing Hospital Adverse Events.” Journal of Patient Safety (January 2016) © 2016 Lippincott Williams & Wilkins https://orcid.org/0000-0001-6294-8890 en_US http://dx.doi.org/10.1097/PTS.0000000000000263 Journal of Patient Safety Creative Commons Attribution-Noncommercial-Share Alike http://creativecommons.org/licenses/by-nc-sa/4.0/ application/pdf Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins Prof. Leveson |
| spellingShingle | Samost, Aubrey Dekker, Sidney Finkelstein, Stan Raman, Jai Leveson, Nancy G A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title | A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title_full | A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title_fullStr | A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title_full_unstemmed | A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title_short | A Systems Approach to Analyzing and Preventing Hospital Adverse Events |
| title_sort | systems approach to analyzing and preventing hospital adverse events |
| url | http://hdl.handle.net/1721.1/115366 https://orcid.org/0000-0001-6294-8890 |
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