Using system analysis to build a safety culture: improving the reliability of epidural analgesia

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.