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New methods for reducing adverse events and harmful overuse


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").


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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