title: Analyze process changes to identify system failures.
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.
authors.affiliation: Brown-Spath Associates, Forest Grove, OR, USA.
authors.forename: P
authors.initials: P
authors.lastname: Spath
mesh_terms: D006739:Hospital Administration / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D009936:Organizational Innovation; D017064:Process Assessment, Health Care / Q000379:methods*; D012308:Risk Management / Q000379:methods; D018571:Sentinel Surveillance; D013597:Systems Analysis; D014481:United States