Closing the Loop by Operationalizing Systems Engineering and Design (CLOSED)
Motivation:
Specific Aims :
Aim 1:​Use systems engineering and patient engagement to design, develop, and refine a highly reliable “closed loop” system for diagnostic tests and referrals that ensures diagnostic orders and follow-up occur reliably within clinically- and patient-important time-frames.
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Aim 2: Use systems engineering and patient engagement to design, develop, and refine a highly reliable “closed loop” system for symptoms that ensures clinicians receive and act on feedback about evolving symptoms and physical findings of concern to patients or clinicians.
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Aim 3: Design for generalizability across health systems more broadly so that the processes created in Aims 1 and 2 are effective in (1) a practice in an underserved community, (2) a large tele-medicine system, and (3) a representative range of simulated other health system settings and populations.
Partners:
Sunday, June 2, 2019
Sunday, June 2, 2019
Approach:
Sunday, June 2, 2019
Results to Date:
New methods for reducing adverse events and harmful overuse
About
With emerging new approaches to patient safety, adverse events (AEs) and harmful overuse are a widespread problem across healthcare. The objective of this project was to research and integrate both existing and new methods for analyzing and reducing adverse events (AEs), patient exposure to harm, and associated costs.
Our research team used hybrid methods to assess and apply complexity systems failure analysis methods from the emerging "Safety-2" field, building on a past CHOT project ("Improvements to Root Cause Analysis of Patient Safety Events").
Results
We conducted a Systems-Theoretic Process Analysis (STPA) at Brigham and Women's Hospital to improve safety of their opioid prescription management system. The team identified two major unacceptable losses (opioid-related patient harm and difficulty in obtaining a necessary prescription), ten hazards related to these losses, forty-two unsafe control actions, and sixteen suggested controls. The majority of suggested improvements require customizing existing databases and creating an opioid resource team to support the system.
Project Team
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Joe Eisner
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Karen Chen
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Saytan Chari