A system analysis of a suboptimal surgical experience.

Patient Safety in Surgery
Robert C LeeMichael Richards

Abstract

System analyses of incidents that occur in the process of health care delivery are rare. A case study of a series of incidents that one of the authors experienced after routine urologic surgery is presented. We interpret the sequence of events as a case of cascading incidents that resulted in outcomes that were suboptimal, although fortunately not fatal. A system dynamics approach was employed to develop illustrative models (flow diagrams) of the dynamics of the patient's interaction with surgery and emergency departments. The flow diagrams were constructed based upon the experience of the patient, chart review, discussion with the involved physicians as well as several physician colleagues, comparison of our diagrams with those developed by the hospital of interest for internal planning purposes, and an iterative process with one of the co-authors who is a system dynamics expert. A dynamic hypothesis was developed using insights gained by building the flow diagrams. The incidents originated in design flaws and many small innocuous system changes that have occurred incrementally over time, which by themselves may have no consequence but in conjunction with some system randomness can have serious consequences. In the patient's c...Continue Reading

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Apr 14, 2011·Journal of the American Medical Informatics Association : JAMIA·Adam G DunnWayne Wobcke
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