System-Oriented Event Analysis Model for Patient Safety Enhancement

• Main Authors: Sheuwen Chuang, 莊秀文
• Other Authors: Chung-Yu Pan
• Format: Others
• Language: zh-TW
• Published: 2008
• Online Access: http://ndltd.ncl.edu.tw/handle/39976144372948409012

博士 === 東海大學 === 工業工程與經營資訊學系 === 96 === Patient safety has become a major concern throughout the world. Changes in 「systems」 of care and applications of risk management have been recognized as a key for the successful implementation of patient safety; however, the performances of patient safety have not been satisfactory and acceptable. Resources limitation and a lack of knowledge and understanding of errors are the major barriers to block the success. In order to break through these barriers, a four-step System-Oriented Event analysis model (SOEA) is proposed based on system theory, control theory, socio-technical system risk management model, and accident model. 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. The case study in a small community hospital has shown positive impacts on patient safety and the knowledge enhancement of errors and system control. However, an improvement in individual patient safety system does not mean the enhancement of overall patient safety in a hospital. A preliminary design of Enterprise Patient Safety Management (EPSM) model has been explored in the research additionally. The result of exploration of EPSM model directs the future work in the research. To improve patient safety is more than just the absence of errors and looking for the root causes, the solutions have to be found in the broader system context either for individual patient safety issue or the overall patient safety problems in hospital. Consequently, health care institutions could be moved from short-term, isolated performance improvements to sustained, reliable, enterprise wide improvements in patient care.