RESUMO
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. DISCUSSION: 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.
