Reliable Systems Summary

Reliable Systems Module Summary

The Systems Approach

A healthcare system has many interconnecting parts that must coordinate in a highly systematic manner.

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Reliable Systems

Unreliable Systems

• decreases completely

• respects opinions from junior staff
• considers system causes of errors
• investigates and learns from errors
• prioritizes safety

• complicates processes

• contains hierarchies in the OR that restrict communication
• blames errors on individuals
• does not investigate errors
• prioritizes production

Production Pressure and Workarounds

Technology

Workarounds signal a system failure warranting investigation. Individuals create workarounds to save time.

Technology can prevent errors, but may create additional errors, if:

• the technology is too complex or lacks decision support

• the system lacks education/training support

• production pressure degrades performance

• production pressure may lead to the creation of workarounds

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Healthcare-Associated Infections

Healthcare-associated infections can be mitigated with accurate timing of antibiotics, proper handwashing, and adherence to infection control protocols

Anesthesia professionals have a role in preventing infections

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Changing to a Reliable System

You can initiate strategies and take the lead to improving systems at your institution by:

• creating a safety culture
• identifying system failures
• implementing safety nets and redundancies

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