Systems analysis methodology handbook: A coordinated approach to reviewing clinical adverse events and close calls (April 2019)

Summary

When patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance.

Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.

Content

This framework provides staff and medical staff with:

• a standardised methodology including a common analysis language; and
• standardised analysis tools for reviewing clinical adverse events and close calls. 

There are three methodologies described within this handbook that can be used to review clinical Adverse Events. These methodologies are designed to suit the scope of a clinical adverse event or multiple clinical adverse events, and provide flexibility for the user.

• The Concise method is commonly used for a succinct review of close calls or clinical adverse events that result in no, low, or moderate harm to the patient or may focus on a new event for which a Comprehensive analysis was recently completed. The concise method is generally used for reviews conducted by one or two individuals.
• The Comprehensive method is used for a thorough review of a single clinical adverse event and involves a team approach.
• The Aggregate method involves a thorough review of multiple clinical adverse events and/or quality assurance reviews. This method is resource intensive and involves a team approach.