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A FRAM (Functional Resonance Analysis Method) analysis of labour-and-delivery: Locating risk in a complex system
KTH, School of Technology and Health (STH), Health Systems Engineering, Systems Safety and Management.
KTH, School of Technology and Health (STH), Health Systems Engineering, Systems Safety and Management.
Number of Authors: 6
2014 (English)Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Although outcomes in labour-and-delivery are generally good, the danger of rare catastrophic events is always present. Two fetal deaths in the labour-and-delivery suite in Jönköping had been analysed with root cause analysis (RCA). Those RCA’s did not identify common causes and RCA-derived countermeasures seemed narrowly reactive and insufficiently robust. The variable, unpredictable workload and high stakes found in a labour-and-delivery suite creates critical dependencies, and vulnerabilities that vary over time. The potential for resonance etween these dependencies is a systemic problem that is missed by RCA. In general RCA  does not lead to a deeper understanding of how systems function and how systems usually  works to prevent catastrophic outcomes. RCA might therefore not work as a system improvement tool. The aim of this study was to explore if a FRAM analysis could give better nderstanding of circumstances important for patient safety in labour-and-delivery not evident from previous RCA’s.

Place, publisher, year, edition, pages
2014.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:kth:diva-154359OAI: oai:DiVA.org:kth-154359DiVA: diva2:756822
Conference
International Forum on Quality and Safety in healthcare, 08/04/14 - 11/04/14, Paris, France
Note

QC 20150210

Available from: 2014-10-20 Created: 2014-10-20 Last updated: 2015-02-10Bibliographically approved

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CiteExportLink to record
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Citation style
  • apa
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Language
  • de-DE
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  • en-US
  • fi-FI
  • nn-NO
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  • Other locale
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Output format
  • html
  • text
  • asciidoc
  • rtf