© 2009 On the CUSP: STOP BSI Identifying Hazards.
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Transcript of © 2009 On the CUSP: STOP BSI Identifying Hazards.
© 2009
Learning ObjectivesLearning Objectives
• To learn how to identify hazards in a system
• To learn different risk analysis methods and risk management strategies
© 2009
Safety EngineeringSafety Engineering
• Build safety into design of systems
• Proactively identify hazards in the system before errors and accidents occur
• Develop risk management strategies
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TerminologyTerminology
• Harm (adverse) events
• No harm events
• Near misses
• Hazard: Source of danger but does not contain any likelihood of an undesired impact
• Risk analysis: Detailed examination of – what hazards can happen– how likely a hazard will happen– what are the consequences, if such a hazard happens in the
system
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Hazard and Risk Analysis Tools Hazard and Risk Analysis Tools - Reactive- Reactive
• Archival records
• Event reporting
• Root cause analysis
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Identifying Hazards- Identifying Hazards- ProactiveProactive
• Work system analysis or process mapping
• Observations
• Interviews or focus groups
• Brainstorming
• Heuristic analysis
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What to Observe?What to Observe?
• Physical layout
• Disconnects and surprises (e.g., automation surprises)
• Distractions
• Ambiguities
• Workarounds
• Team behaviors (e.g. situation awareness,
shared mental model)
Information tool characteristics
Extreme, unexpected, unfamiliar cases
Feedback mechanisms
Variations in conducting tasks
Fit to the job (e.g., task-technology fit)
© 2009
Observation Tool for Observation Tool for Identifying HazardsIdentifying Hazards
Hazards
TaskPeople involved
Tools/ technologies used
Environment
Organizational structure
System Ambiguities
Workarounds
Trigger(s) for hazard
ConsequencesRisk management strategies currently used
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Interviews/ Focus GroupsInterviews/ Focus Groups
• What could go wrong? How badly will it go wrong?
• How do you think that patients can be harmed in this unit while taken care of?
• If you could change a few things in your unit to improve patient safety, what would they be?
• What safeguards are in place to prevent errors?
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Risk AnalysisRisk Analysis
Hazards CausesSeverit
yFrequency
Detectability
Priority
scoreAction
Responsible party
Target date
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Risk Reduction Risk Reduction StrategiesStrategies
• Simplify and standardize when you can
• Create independent checkpoints
• Learn from mistakes
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• Eliminate the risk(s)
• Make it easier for people to do the right thing (e.g., central line insertion cart)
• Make it harder to do the wrong thing (e.g., standardized orders, making it physically impossible to insert the wrong cable or tube into a particular port)
• Increase error detection and recovery (fault-tolerant systems)
• Train and retrain
• Create a safe reporting environment (hazard reporting in addition to adverse event reporting and learning mechanism)
Risk Reduction Risk Reduction StrategiesStrategies
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Action PlanAction Plan
Action: Conduct risk analysis for CLABSI
• Form an interdisciplinary risk management group (physician, nurse, inf control, resp. therapy, human factors, other)
• Identify hazards– Conduct work system analysis– Observations and walk-throughs, interviews with front-line staff
• Compile findings in the “risk analysis table.”
• Discuss findings in an interdisciplinary meeting (including unit administrators), prioritize risks and develop an action plan for risk management
• Review the progress periodically and modify the risk management plan
© 2009
ReferencesReferences
• Battles and Lilford (2003). Organizing patient safety research to identify risks and hazards. QSHC 12:ii2-ii7.
• Carayon et al. (2006). Works system design for patient safety: the SEIPS model. QSHC 15: i50 - i58.
• DeRosier et al. (2002). Using health care failure mode and effect analysisTM. Joint Commission Journal on Quality Improvement. 28: 248-267.
• Gurses et al. (2008). Systems ambiguity and guideline compliance, QSHC 17:351-359.
• Marx and Slonim (2003). Assessing patient safety risk before the injury occurs. QSHC. 12:ii33-ii38.