Implementing systems thinking for infection prevention: The cessation of repeated scabies outbreaks in a respiratory care ward

Sheuwen Chuang, Peter P. Howley, Shih Hua Lin

Research output: Contribution to journalArticlepeer-review

7 Citations (Scopus)


Background Root cause analysis (RCA) is often adopted to complement epidemiologic investigation for outbreaks and infection-related adverse events in hospitals; however, RCA has been argued to have limited effectiveness in preventing such events. We describe how an innovative systems analysis approach halted repeated scabies outbreaks, and highlight the importance of systems thinking for outbreaks analysis and sustaining effective infection prevention and control. Methods Following RCA for a third successive outbreak of scabies over a 17-month period in a 60-bed respiratory care ward of a Taiwan hospital, a systems-oriented event analysis (SOEA) model was used to reanalyze the outbreak. Both approaches and the recommendations were compared. Results No nosocomial scabies have been reported for more than 1975 days since implementation of the SOEA. Previous intervals between seeming eradication and repeat outbreaks following RCA were 270 days and 180 days. Achieving a sustainable positive resolution relied on applying systems thinking and the holistic analysis of the system, not merely looking for root causes of events. Conclusion To improve the effectiveness of outbreaks analysis and infection control, an emphasis on systems thinking is critical, along with a practical approach to ensure its effective implementation. The SOEA model provides the necessary framework and is a viable complementary approach, or alternative, to RCA.

Original languageEnglish
Pages (from-to)499-505
Number of pages7
JournalAmerican Journal of Infection Control
Issue number5
Publication statusPublished - May 1 2015


  • Health care-associated infection
  • Root-cause analysis
  • Scabies outbreak
  • Systems thinking
  • Systems-oriented event analysis

ASJC Scopus subject areas

  • Infectious Diseases
  • Public Health, Environmental and Occupational Health
  • Epidemiology
  • Health Policy


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