[Systemic error analysis as a key element of clinical risk management]

Systemic error analysis plays a key role in clinical risk management. This includes all clinical and administrative activities which identify, assess and reduce the risks of damage to patients and to the organization. The clinical risk management is an integral part of quality management. This is also the policy of the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) on the fundamental requirements of an internal quality management. The goal of all activities is to improve the quality of medical treatment and patient safety. Primarily this is done by a systemic analysis of incidents and errors. A results-oriented systemic error analysis needs an open and unprejudiced corporate culture. Errors have to be transparent and measures to improve processes have to be taken. Disciplinary action on staff must not be part of the process. If these targets are met, errors and incidents can be analyzed and the process can create added value to the organization. There are some proven instruments to achieve that. This paper discusses in detail the error and risk analysis (ERA), which is frequently used in German healthcare organizations. The ERA goes far beyond the detection of problems due to faulty procedures. It focuses on the analysis of the following contributory factors: patient factors, task and process factors, individual factors, team factors, occupational and environmental factors, psychological factors, organizational and management factors and institutional context. Organizations can only learn from mistakes by analyzing these factors systemically and developing appropriate corrective actions. This article describes the fundamentals and implementation of the method at the University Medical Center Hamburg-Eppendorf.