title: Systems analysis of a clinical error.
abstract: Systems analysis is an approach used in situations requiring high reliability. In the past, the investigation and prevention of clinical error focused on the actions of individuals. A systems analysis approach to medical errors can identify and correct multiple contributing factors resulting in safer patient care systems. Recent analysis of a clinical error that occurred in public health practice identified multiple factors contributing to its occurrence. The use of the systems analysis approach resulted in high staff satisfaction and creative suggestions for operating a safer clinic and providing better patient care.
authors.affiliation: City of Amarillo (Texas), Department of Public Health, Amarillo, Texas, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Denison
authors.forename: J Rush
authors.initials: JR
authors.lastname: Pierce
mesh_terms: D003151:Community Health Centers / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D015980:Public Health Practice / Q000592:standards*; D011785:Quality Assurance, Health Care; D015203:Reproducibility of Results; D012308:Risk Management / Q000379:methods*; D018571:Sentinel Surveillance; D013597:Systems Analysis; D013781:Texas; D014481:United States