System Safety Analysis

March 1, 2011 | Healthcare Risk, Quality, & Safety Guidance

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Organizations are complex systems of people, technology, property, and other features—all in constant interaction with one another. If there is a problem with any of the interactions, accidents can occur. Indeed, in every system—and particularly in healthcare organizations—there are infinite opportunities for accidents and mishaps, and the results can range from inconsequential to disastrous.

Organizations that adopt a comprehensive approach to system safety can ensure that measures are in place to prevent foreseeable accidents and to minimize the harm from unforeseen ones (Leveson). Organizations use the tools of system safety analysis to identify dangerous aspects within their systems and to correct those dangers, as well as to learn from accidents to prevent further harm to all components of the system.

This Risk Analysis will review the concepts of system safety and summarize two important approaches to ensure safe systems: predictive analysis and reactive analysis. Predictive analysis is used to preemptively identify hazards within systems so that the organization can adopt strategies to eliminate the hazards and prevent harm to people and property, whereas reactive analysis is used after an accident occurs to identify the weaknesses within a system that allowed the errors to occur and, most importantly, to identify measures to prevent similar mishaps. Reactive analysis can also be used after near-miss events to correct problems before they lead to actual accidents.

Most of the concepts for system safety were born at the end of World War II. Organizations moved from a reactive, trial-and-error philosophy that dominated the first half of the 20th century to a much more proactive, systematic approach to analyzing and mitigating hazards. Until then, many of the early safety techniques were analogous to the “fly-fix-fly” method the Wright brothers employed in their quest to be first in flight.

By 1969, the U.S. Department of Defense (DoD) established a standard for system safety for its contractors that pulled together the fundamental concepts for system safety still in place today (Leveson). Known as Military Standard 882, the standard requires that contractors that work for DoD have a process in place that stresses proactive safety. Still used today, the 2000 version of the standard clearly states the requirements for a system safety program, which could apply to any organization committed to system safety. These requirements include the...

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