Application of a Systems Theory-Based Accident Analysis Technique to Perioperative Safety Reports From the COVID-19 Pandemic.

IF 1.7 3区 医学 Q3 HEALTH CARE SCIENCES & SERVICES
Aubrey L Samost-Williams, Robert D Sinyard, Leo L Tabayoyong, Joseph R Fogarty, Rebecca D Minehart, Karen C Nanji
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Abstract

Objectives: Nonlinear retrospective analytic techniques can allow for in-depth understanding of accidents and their causes, yet they are infrequently used in health care. The purpose of this study was to provide an example, using Causal Analysis based on Systems Theory (CAST) together with an inductive thematic analysis to understand the contextual factors contributing to one hospital's perioperative safety events.

Methods: We created a hierarchical control structure of the hospital's perioperative system with input from a multidisciplinary group. We then analyzed safety events that were self-reported during a COVID surge (April 2020) using CAST to understand their contributing factors. Next, we analyzed the contributing factors using inductive qualitative thematic coding to identify system-level safety risks. We mapped each system-level safety risk to a recommendation for future mitigation.

Results: We screened 122 safety reports and found 19 safety events that met inclusion criteria. The analysis revealed 245 contributing factors represented by 22 subthemes corresponding to 3 major themes: (1) vulnerable processes, being problems with workflows or communication channels; (2) personnel challenges including challenges with staff redeployment as well as cognitive and behavioural challenges; and (3) poorly designed or unavailable equipment. Each subtheme corresponded to a prevention strategy, such as creation of a central protocol hub.

Conclusions: Using a nonlinear accident analysis technique together with thematic analysis, we were able to identify system-wide contributing factors to safety events. These contributing factors led to recommendations for future pandemics or crises characterized by scarce resources, limited data, and a rapidly changing environment.

基于系统理论的事故分析技术在新冠肺炎大流行围手术期安全报告中的应用
目的:非线性回顾性分析技术可以深入了解事故及其原因,但在医疗保健中很少使用。本研究的目的是提供一个例子,使用基于系统理论的因果分析(CAST)和归纳主题分析来了解影响一家医院围手术期安全事件的背景因素。方法:我们根据多学科小组的意见,建立了医院围手术期系统的分层控制结构。然后,我们使用CAST分析了在COVID激增(2020年4月)期间自我报告的安全事件,以了解其影响因素。其次,我们使用归纳定性主题编码来分析影响系统安全风险的因素。我们将每个系统级安全风险映射到未来缓解的建议中。结果:我们筛选了122份安全报告,发现19个安全事件符合纳入标准。分析揭示了245个影响因素,这些因素由22个子主题代表,对应于3个主要主题:(1)易受攻击的流程,即工作流程或沟通渠道的问题;(2)人员挑战,包括人员调动挑战以及认知和行为挑战;(3)设计不良或设备不可用。每个次级主题对应一项预防战略,例如建立一个中央协议中心。结论:使用非线性事故分析技术和专题分析,我们能够确定安全事件的全系统贡献因素。这些促成因素导致对未来以资源稀缺、数据有限和环境迅速变化为特征的流行病或危机提出建议。
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来源期刊
Journal of Patient Safety
Journal of Patient Safety HEALTH CARE SCIENCES & SERVICES-
CiteScore
4.60
自引率
13.60%
发文量
302
期刊介绍: Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.
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