Beyond Root Cause Analysis: An Enriched System Oriented Event Analysis Model for Wide Application

摘要

An elementary System Oriented Event Analysis (SOEA) model was developed as an innovative method addressing serious limitations of the traditional root cause analysis (RCA) in healthcare. The SOEA has three distinctive capabilities beyond RCA: multiple events analysis, systems thinking, risk control formulation and alignment. It was applicable to events arising within strict sequential processes. However, for wider application to nonsequential, network system flows, the model needed to be redesigned. The engineering concepts of verification and validation were adopted as guides for the redesign. Patient falls in three differently sized hospitals were used to verify the applicability of the redesigned model. The resulting enriched SOEA model (enSOEA) was later applied in a scabies outbreak case as a validation test of success. This paper aims to describe how the elementary SOEA model was redesigned to achieve the enriched SOEA that is applicable beyond the sequential process, and provides key lessons learned from the tests for promoting its application.