title: Using system analysis to build a safety culture: improving the reliability of epidural analgesia.
abstract: BACKGROUND
  A potentially dangerous situation was revealed by an incident report describing the use of an inappropriate device to administer post-operative epidural analgesia to a patient on a surgical ward. The incident occurred in a 1200-bed university affiliated tertiary hospital (Geneva University Hospitals, HUG) and involved three clinical departments: anaesthesiology, the surgical intensive care unit and urology.
  
  
  METHODS
  A multidisciplinary system analysis was carried out to identify care-delivery problems and contributory factors. Corrective actions were devised on the basis of their ability to prevent and absorb unsafe situations.
  
  
  RESULTS
  The system analysis identified three care-delivery problems in relation to the management of epidural analgesia. It enabled medical and nursing managers to adopt an interdepartmental set of corrective actions: a common protocol for post-operative epidural analgesia, leading to the exclusive use of patient-controlled epidural analgesia (PCEA) pumps; greater availability of the patient-controlled pumps; the dissemination of guidelines; permanent proactive training of nurses by the acute-pain team; the clarification of medical responsibilities; and a common help-line phone number for all surgical departments.
  
  
  CONCLUSIONS
  The analysis provided a convincing exposure of various care-delivery problems and their corresponding contributory factors, as well as an opportunity to address a systemic issue in a multidisciplinary way. By thus facilitating decisions and corrective actions, the analysis was instrumental in strengthening our safety culture.
authors.affiliation: Anaesthesiology Service, Department of Anaesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland. philippe.garnerin@hcuge.ch
authors.forename: P
authors.initials: P
authors.lastname: Garnerin
authors.forename: A
authors.initials: A
authors.lastname: Huchet-Belouard
authors.forename: M
authors.initials: M
authors.lastname: Diby
authors.forename: F
authors.initials: F
authors.lastname: Clergue
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects* / Q000295:instrumentation; D016058:Analgesia, Patient-Controlled; D002983:Clinical Competence; D017408:Guidelines as Topic; D006801:Humans; D007260:Infusion Pumps; D008297:Male; D009726:Nurses; D015279:Organizational Culture; D010149:Postoperative Pain / Q000188:drug therapy; D010348:Patient Care Team; D011785:Quality Assurance, Health Care; D012308:Risk Management; D012449:Safety; D013597:Systems Analysis