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.
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