摘要
Applications of system approach and changes in "systems"of care have been recognized as a key for the successful implementation of patient safety; however, the performances of patient safety have neither been satisfactory nor acceptable. The lack of knowledge and understanding of errors is one of the major barriers in blocking the success. In this paper, a four-step System Oriented Event Analysis model is proposed based on system theory and risk management model for social-technical systems. It reflects both a philosophical approach and a mechanism to guide the investigation team to build up the ability of controlling safety in the way of system thinking. A pilot study in a 50-bed hospital was performed. The system knowledge of errors for health care professionals has been strengthened during the model implementation. The system hierarchy and safety control matrix for vulnerable system components in the outpatient clinic consultation system has been established to prevent patient identification errors. A reduction of this type of error and the increase of incidents reported were found after ten months of implementation. Health care institutions can use this model as a training instrument for system knowledge enhancement, and as an analysis mechanism for the sustainability of patient safety.
| 原文 | 英語 |
|---|---|
| 頁（從 - 到） | 218-232 |
| 頁數 | 15 |
| 期刊 | Systems Engineering |
| 卷 | 12 |
| 發行號 | 3 |
| DOIs | |
| 出版狀態 | 已發佈 - 九月 2009 |
| 對外發佈 | Yes |
指紋
ASJC Scopus subject areas
- Computer Networks and Communications
- Hardware and Architecture
引用此文
A system-oriented analysis model to enhance patient safety in healthcare organizations. / Chuang, Sheu-Wen; Pan, Chung Yu; Huang, Chin Yin.
於: Systems Engineering, 卷 12, 編號 3, 09.2009, p. 218-232.研究成果: 雜誌貢獻 › 文章
}
TY - JOUR
T1 - A system-oriented analysis model to enhance patient safety in healthcare organizations
AU - Chuang, Sheu-Wen
AU - Pan, Chung Yu
AU - Huang, Chin Yin
PY - 2009/9
Y1 - 2009/9
N2 - Applications of system approach and changes in "systems"of care have been recognized as a key for the successful implementation of patient safety; however, the performances of patient safety have neither been satisfactory nor acceptable. The lack of knowledge and understanding of errors is one of the major barriers in blocking the success. In this paper, a four-step System Oriented Event Analysis model is proposed based on system theory and risk management model for social-technical systems. It reflects both a philosophical approach and a mechanism to guide the investigation team to build up the ability of controlling safety in the way of system thinking. A pilot study in a 50-bed hospital was performed. The system knowledge of errors for health care professionals has been strengthened during the model implementation. The system hierarchy and safety control matrix for vulnerable system components in the outpatient clinic consultation system has been established to prevent patient identification errors. A reduction of this type of error and the increase of incidents reported were found after ten months of implementation. Health care institutions can use this model as a training instrument for system knowledge enhancement, and as an analysis mechanism for the sustainability of patient safety.
AB - Applications of system approach and changes in "systems"of care have been recognized as a key for the successful implementation of patient safety; however, the performances of patient safety have neither been satisfactory nor acceptable. The lack of knowledge and understanding of errors is one of the major barriers in blocking the success. In this paper, a four-step System Oriented Event Analysis model is proposed based on system theory and risk management model for social-technical systems. It reflects both a philosophical approach and a mechanism to guide the investigation team to build up the ability of controlling safety in the way of system thinking. A pilot study in a 50-bed hospital was performed. The system knowledge of errors for health care professionals has been strengthened during the model implementation. The system hierarchy and safety control matrix for vulnerable system components in the outpatient clinic consultation system has been established to prevent patient identification errors. A reduction of this type of error and the increase of incidents reported were found after ten months of implementation. Health care institutions can use this model as a training instrument for system knowledge enhancement, and as an analysis mechanism for the sustainability of patient safety.
KW - Patient safety
KW - Safety control structure
KW - System-oriented event analysis
UR - http://www.scopus.com/inward/record.url?scp=70350345230&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=70350345230&partnerID=8YFLogxK
U2 - 10.1002/sys.20120
DO - 10.1002/sys.20120
M3 - Article
AN - SCOPUS:70350345230
VL - 12
SP - 218
EP - 232
JO - Systems Engineering
JF - Systems Engineering
SN - 1098-1241
IS - 3
ER -