TY - JOUR
T1 - Implementing systems thinking for infection prevention
T2 - The cessation of repeated scabies outbreaks in a respiratory care ward
AU - Chuang, Sheuwen
AU - Howley, Peter P.
AU - Lin, Shih Hua
N1 - Publisher Copyright:
© 2015 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.
PY - 2015/5/1
Y1 - 2015/5/1
N2 - 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.
AB - 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.
KW - Health care-associated infection
KW - Root-cause analysis
KW - Scabies outbreak
KW - Systems thinking
KW - Systems-oriented event analysis
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U2 - 10.1016/j.ajic.2015.02.002
DO - 10.1016/j.ajic.2015.02.002
M3 - Article
C2 - 25798774
AN - SCOPUS:84929508120
SN - 0196-6553
VL - 43
SP - 499
EP - 505
JO - American Journal of Infection Control
JF - American Journal of Infection Control
IS - 5
ER -