Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems
Structural Approaches to Address Issues in Patient Safety
ISBN: 978-1-83867-085-6, eISBN: 978-1-83867-084-9
Publication date: 24 October 2019
Abstract
Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.
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Acknowledgements
Acknowledgments
This work was supported by the Agency for Healthcare Research and Quality (grant number P30HS024403). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors gratefully acknowledge the contributions of analysts Colin Skinner and Jennifer Snide to historical data collection and analysis. We also recognize Eugene Korsunskiy, PhD, Amir Gaferi, MD, and the many clinical, operational, and industry (Masimo, Inc.) participants in the Failure to Rescue Learning Laboratory design workshops.
Citation
McGrath, S.P., Wells, E., McGovern, K.M., Perreard, I., Stewart, K., McGrath, D. and Blike, G. (2019), "Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems", Structural Approaches to Address Issues in Patient Safety (Advances in Health Care Management, Vol. 18), Emerald Publishing Limited, Leeds, pp. 119-157. https://doi.org/10.1108/S1474-823120190000018006
Publisher
:Emerald Publishing Limited
Copyright © 2019 Emerald Publishing Limited