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Effectiveness of systems changes suggested by simulation of adverse surgical outcomes
  1. Meghan E Garstka,
  2. Douglas P Slakey,
  3. Christopher A Martin,
  4. Eric R Simms,
  5. James R Korndorffer Jr
  1. Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
  1. Correspondence to James R Korndorffer, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, 70118, SL-22, New Orleans, LA 70118 USA; korndorffer{at}


Background Simulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes.

Methods Systems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed.

Results In seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned.

Conclusions Systems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

  • root cause analysis (RCA)
  • systems theory
  • simulation
  • surgery
  • outcomes

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