Microsystems in health care: Part 6. Designing patient safety into the microsystem.
BACKGROUND
This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures.


METHODS
The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients.


CONCLUSIONS
Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.
Mohr
Julie J
JJ
Department of Anesthesia and Critical Care, University of Chicago, Chicago, USA.
Barach
Paul
P
Cravero
Joseph P
JP
Blike
George T
GT
Godfrey
Marjorie M
MM
Batalden
Paul B
PB
Nelson
Eugene C
EC
D000046:Academic Medical Centers / Q000458:organization & administration / Q000592:standards*; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D009513:New Hampshire; D019982:Organizational Case Studies; D017064:Process Assessment, Health Care; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000379:methods*; D012985:Software Design; D013597:Systems Analysis; D014481:United States