Every clinical care system contains inherent functions and attributes. To better understand how those system functions and attributes work, or more properly stated, how they work better for you, we conduct a clinical care systems analysis. We begin by analyzing the clinical care system you’ve selected (medication administration, labor and delivery, emergency services, ICU, etc.) and build what we call a System Safety Architecture. The System Safety Architecture presents a visual map of your selected system that specifically identifies supporting sub-systems and associated working-level processes. To illustrate:

We need to “drill-down” to the working-level process because at the system and sub-system levels the ability to collect meaningful data is not possible as they are too vague. The working-level process is where clinical care tasks are carried out, sometimes individually, sometimes in teams, and many times in conjunction with other systems and processes. At this level in your system we are now able to collect meaningful data for assessment, analysis, and dissemination.

Once the System Safety Architecture is complete we analyze each process for specific system safety attributes and functions including:

• Responsibility
• Authority
• Procedures
• Controls
• Risk-Point Process Measurements
• Interfaces

Next, we assign a risk classification to all identified system hazards. Risk classification assignments are presented in a Risk Prioritization Framework as HIGH, MEDIUM, or LOW and are only presented after each is vetted for relative implementation difficulty. Implementation difficulty considerations include system stability implications, regulatory compliance, cost-benefit, resources available, and time to implement.

Finally, we make patient safety recommendations that specifically consider system safety design and functionality, Safety Order of Precedence design criteria, and human factors engineering principles.

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