On the CUSP: STOP BSI
Identifying Hazards
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Learning 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 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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Terminology
• 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 Reactive
• Archival records
• Event reporting
• Root cause analysis
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Identifying HazardsProactive
• Work system analysis or process mapping
• Observations
• Interviews or focus groups
• Brainstorming
• Heuristic analysis
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What to Observe?
• Physical layout
 Information tool characteristics
• Disconnects and surprises
(e.g., automation surprises)
 Extreme, unexpected,
• Distractions
 Feedback mechanisms
• Ambiguities
 Variations in conducting tasks
• Workarounds
 Fit to the job
unfamiliar cases
(e.g., task-technology fit)
• Team behaviors
(e.g. situation awareness,
shared mental model)
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Observation Tool for
Identifying Hazards
Hazards
Task
People
involved
Tools/
technologies Environment
used
Organizational
structure
System
Ambiguities
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Workarounds
Trigger(s)
for hazard
Consequences
Risk management
strategies currently
used
Interviews/ 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 Analysis
Hazards
Causes
Severity
Frequency
Detectability
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Priority
score
Action
Responsible
party
Target
date
Risk Reduction Strategies
• Simplify and standardize when you can
• Create independent checkpoints
• Learn from mistakes
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Risk Reduction Strategies
• 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)
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Action 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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References
•
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: 248267.
•
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.
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