Journal of patient safety
-
Journal of patient safety · Jun 2020
A Systems Approach to Analyzing and Preventing Hospital Adverse Events.
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. ⋯ 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.