ABSTRACT
This chapter highlights important general principles such as breadth before depth and functional resonance, and methodological 'tricks' that can be learned from the case. The case study illustrates how the Resilience Health Care (RHC) principles can be turned into practice using the Functional Resonance Analysis Method (FRAM). In 2012 and 2013 a recurrent patient safety theme was recognised and addressed but persisted despite continuing plan-do-study-act (PDSA) cycles. PDSA cycles had addressed the attention towards the adverse events and the existing guidelines to be followed in regards to enhancing patient safety. The Quality and Patient Safety team found that a systemic approach was needed to investigate this patient safety problem in order to match and validate further quality improvement initiatives. Due to strategic re-organisation, the Spine Center of Southern Denmark has undergone several fundamental changes, causing a shift in focus towards other patient safety themes to be addressed.
