Microsystems in health care: Part 6. Designing patient safety into the microsystem.

Julie J. Mohr*, Paul Barach, Joseph P. Cravero, George T. Blike, Marjorie M. Godfrey, Paul B. Batalden, Eugene C. Nelson

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

58 Scopus citations


BACKGROUND: This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures. CASE STUDY: The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients. CONCLUSION: Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.

Original languageEnglish (US)
Pages (from-to)401-408
Number of pages8
JournalJoint Commission journal on quality and safety
Issue number8
StatePublished - Aug 2003

ASJC Scopus subject areas

  • Medicine(all)


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