Search PubMed⌕ Search
Home/Archive/PubMed

PubMed · 11184102

Analyze process changes to identify system failures.

P Spath
View original source ↗Export metadata ↓

Abstract

In this month's Quality-Co$t Connection, consulting editor Patrice Spath, RHIT, emphasizes that undesirable patient incidents are often caused by slight changes in the usual process of care. Deviations in system operations can be planned and desired or unintended and unwanted. Change analysis can help you analyze the effects of such deviations and can be a useful tool during sentinel event investigations.

Explore related subjects

Hospital AdministrationHumansMedical ErrorsOrganizational InnovationProcess Assessment, Health CareRisk ManagementSentinel SurveillanceSystems AnalysisUnited StatesJournal Article

Keep this discovery

Explore connections, maps & timelines

BibTeXRIS

P Spath. 2000. Analyze process changes to identify system failures.. https://pubmed.ncbi.nlm.nih.gov/11184102/

Cite the original work for its findings. Save a collection to share your selection of sources.

KEEP EXPLORING

Related citations

PubMed2001

Hospital policy on appropriate use of life-sustaining treatment. University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force.

OBJECTIVE: To describe the issues faced, and how they were addressed, by the University of Toronto Critical Care Medicine Program/Joint Centre for Bioethics Task Force on Appropriate Use of Life-Sustaining Treatment. The clinical problem addressed by the Task Force was dealing with requests by patients or substitute decision makers for life-sustaining treatment that their healthcare providers believe is inappropriate. DESIGN: Case study. SETTING: The University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force on Appropriate Use of Life-Sustaining Treatment. PARTICIPANTS: The 24-member Task Force included physician and nursing leaders from five critical care units, bioethicists, a legal scholar, a health administration expert, a social worker, and a hospital public relations professional. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our specific lessons learned include a) a policy focus on process; b) use of a negotiation and mediation model, rather than a hospital ethics committee model, for this process; and c) the policy development process is itself a negotiation, so we recommend equal involvement of interested groups including patients, families, and the public. CONCLUSIONS: This article describes the key issues faced by the Task Force while developing its policy. It will provide a useful starting point for other groups developing policy on appropriate use of life-sustaining treatment.

Hospital Administration↗