PSNet: Systems Approach

• Communication problems
• Human error
• Organisation / service factors
• Patient harmed
• Surgery - General
• System safety
• Work / environment factors

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https://www.pslhub.org/learn/improving-patient-safety/disasters-averted-near-misses/in-health-care/psnet-systems-approach-r372/

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by Claire Cox (edited)

14 August, 20197 yr · 1,957 views

Summary

The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation.

Content

In this article they use this case to highlight the importance of analysing errors using a systems approach. James Reasons 'Swiss cheese model of medical errors' is explained and put into context.

PSNet: Systems Approach https://psnet.ahrq.gov/primers/primer/21

Edited 10 October, 20196 yr by Claire Cox

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https://www.pslhub.org/learn/improving-patient-safety/disasters-averted-near-misses/in-health-care/psnet-systems-approach-r372/

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