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Using system analysis to build a safety culture: improving the reliability of epidural analgesia
Author(s) -
Garnerin P.,
HuchetBelouard A.,
Diby M.,
Clergue F.
Publication year - 2006
Publication title -
acta anaesthesiologica scandinavica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.738
H-Index - 107
eISSN - 1399-6576
pISSN - 0001-5172
DOI - 10.1111/j.1399-6576.2006.01098.x
Subject(s) - medicine , multidisciplinary approach , patient safety , medical emergency , safety culture , protocol (science) , intensive care medicine , health care , alternative medicine , social science , management , pathology , sociology , economics , economic growth
Background: A potentially dangerous situation was revealed by an incident report describing the use of an inappropriate device to administer post‐operative epidural analgesia to a patient on a surgical ward. The incident occurred in a 1200‐bed university affiliated tertiary hospital (Geneva University Hospitals, HUG) and involved three clinical departments: anaesthesiology, the surgical intensive care unit and urology. Methods: A multidisciplinary system analysis was carried out to identify care‐delivery problems and contributory factors. Corrective actions were devised on the basis of their ability to prevent and absorb unsafe situations. Results: The system analysis identified three care‐delivery problems in relation to the management of epidural analgesia. It enabled medical and nursing managers to adopt an interdepartmental set of corrective actions: a common protocol for post‐operative epidural analgesia, leading to the exclusive use of patient‐controlled epidural analgesia (PCEA) pumps; greater availability of the patient‐controlled pumps; the dissemination of guidelines; permanent proactive training of nurses by the acute‐pain team; the clarification of medical responsibilities; and a common help‐line phone number for all surgical departments. Discussion: The analysis provided a convincing exposure of various care‐delivery problems and their corresponding contributory factors, as well as an opportunity to address a systemic issue in a multidisciplinary way. By thus facilitating decisions and corrective actions, the analysis was instrumental in strengthening our safety culture.