Using system analysis to build a safety culture: improving the reliability of epidural analgesia.
Garnerin P, Huchet-Belouard A, Diby M, et al. Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Acta Anaesthesiol Scand. 2006;50(9):1114-9.
The authors describe the systematic analysis of an incident involving inappropriate use of a medical device and discuss how their process for understanding and resolving the problem supported the safety culture in their organization.