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On the CUSP: STOP BSI On the CUSP: STOP BSI Identifying HazardsIdentifying Hazards

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Learning ObjectivesLearning Objectives

• To learn how to identify hazards in a system

• To learn different risk analysis methods and risk management strategies

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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)

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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

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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.