Presentation is loading. Please wait.

Presentation is loading. Please wait.

I ntegration of predictive and retrospective risk analysis in health care Tjerk van der Schaaf Leiden University Medical Center Eindhoven University of.

Similar presentations


Presentation on theme: "I ntegration of predictive and retrospective risk analysis in health care Tjerk van der Schaaf Leiden University Medical Center Eindhoven University of."— Presentation transcript:

1 I ntegration of predictive and retrospective risk analysis in health care Tjerk van der Schaaf Leiden University Medical Center Eindhoven University of Technology

2 overview retrospective method: PRISMA-medical predictive method : HFMEA 3 examples of possible integration –direct comparison of predicted vs actualcauses (radiotherapy) –components combined in a Healthcare Safety Management System (convergent approach) –evaluating major interventions (impact of IT on medication safety)

3 retrospective risk analysis : PRISMA- medical (voluntary) incident reporting and analysis learning from actual / reported process deviations

4 PRISMA-Medical Prevention and Recovery Information System for Monitoring and Analysis Three subsequent steps: –Description by means of causal trees –Classification according to the Eindhoven Classification Model (medical version) –Determination of countermeasures by means of the Classification/Action Matrix

5 Causal tree example Wrong route Lines at same place Nurses not informed Similar lines Connection possible Inadequate check No protocol Catheters not removed No coding O O T TH

6 Eindhoven Classification Model - (medical version)

7 Database Root causes for failure failure profile Root causes for recovery recovery profile Context variables black-spot analysis

8 PRISMA failure profile: hospital medication errors

9 Classification/Action Matrix ECM code Design: Technolo gy/work- place ProceduresInformation and Commu nication TrainingMotiva tion Escala tion Reflection T-EX× TD× TC× TM× O-EX× OK× OP× OM× OC× H-EX× HK_×NO HR_× HS_×NO

10 predictive risk analysis HFMEA / SAFER series of group meetings to build a set of failure scenarios for a (small) process of care : what may go wrong; why; what to do about it pro-active appeal

11 Healthcare Failure Mode and Effect Analysis (HFMEA) A systematic approach to identify and prevent product and process problems before they occur Developed by the "VA National Center for Patient Safety" (http://www.patientsafety.gov/)

12 Relevance of predictive risk analysis Retrospective (incident) analysis takes place after incidents did occur hindsight bias Because of underreporting, biases can arise in incident databases identification of "missing risks"

13 Definitions Failure Mode: Different ways that a process or subprocess can fail to provide the anticipated result (i.e. think of it as what could go wrong) Prescribing the wrong dose Failure Mode Cause: Different reasons as to why a process or subprocess would fail to provide the anticipated result (i.e. think of it as why it would go wrong) Miscalculation

14 HFMEA process Step 1: Define the topic Step 2: Assemble the team Step 3: Graphically describe the process Step 4: Conduct a hazard analysis Step 5: Identify actions and outcome measures

15 examples of integration (1) direct comparison of predicted (HFMEA) vs reported causes user problems with a new radiation therapy technology both types of failure causes expressed in the same PRISMA-medical classification (sub-)categories

16 PRISMA vs HFMEA : main categories 0% 10% 20% 30% 40% 50% 60% Percentage TechOrgHumanother PRISMA main category PRISMA HFMEA : predicted causes

17 PRISMA vs HFMEA : subcategories Frequency category HFMEA less than yearlyyearlymonthlyweekly Weight-factor (= translation to 9 months)0,10,89936

18 examples of integration (2) combining retrospective and predictive components in an overall Healthcare Safety Management System convergent approach of two imperfect risk identification methodologies mutual checks, comparisons, and inputs possible

19 examples of integration (2) continued are repeatedly predicted problems (failure modes) ever being reported? can frequently reported problems help to select suitable processes for HFMEA and generate realistic failure modes? can frequently predicted causes steer the information gathering after an initial report? are proposed interventions for predicted vs reported causes similar? etc…

20 examples of integration (3) developing a process-based evaluation methodology for major (patient safety) interventions predicting and monitoring the impact of IT on medication safety

21 Medication safety: definitions [Van den Bemt et al., 2000]

22 Medication errors: causes (1) Handwritten prescriptions and drug orders Look-alike drug names Sound-alike drugs and verbal orders Use of abbreviations Similar packaging and labelling Inadequate training and supervision Staff shortages Overwork and fatigue [Habraken, 2004]

23 Medication errors: causes (2)

24 IT: possibilities and problems

25 [Bates et al., 1995; Bates, 2000] 56% 6% 4% 34%

26 IT: possibilities and problems IT applicationPROSCONS CPOE Legible prescriptions; no handwriting required Possibility of substitution errors Data entry only necessary onceFailure to warn Exchange of data is easy Computerised decision support Drug informationRisk of low vigilance and overtrust Patient-specific information and advice Bar coding Ensure five "rights": right drug, right patient, right dose, right route, right time Degraded coordination and communication Computerised medical record Legible prescriptions; no handwriting required Possibility of substitution errors Data entry only necessary once Exchange of data is easy [Habraken and Van der Schaaf, 2006]

27 Barriers to the implementation of IT Significant costs: technical, process redesign, and implementation and support Cultural obstacles: resistance to change Privacy and protection of (patient) data Lack of data standards Lack of (clinical) evaluation [Habraken, 2004]

28 Evaluation of effects and impact of IT: PRISMA and HFMEA Not only outcomes of care but also the mechanisms underlying those outcomes Impact of IT on "error recovery " : –Detection –Diagnosis –Correction of earlier errors / deviations

29 Evaluation of effects and impact of IT: PRISMA PRISMA can be used to obtain an insight into the behavioural mechanisms underlying medication errors Classification/Action Matrix enables us to predict which types of human behaviour will be influenced by IT

30 Evaluation of effects and impact of IT: PRISMA ECM code Design/ Technol ProceduresInformation and Communication TrainingMotivationEscalationReflection T-EX× TD× TC× TM× O-EX× OK× OP× OM× OC× H-EX× HK_×NO HR_× HS_×NO

31 Evaluation of effects and impact of IT: PRISMA IT applications would fall in two categories: "technology" and "information and communication" In case of improved technology reduction of skill based human errors In case of information and communication support reduction of knowledge based errors BUT: rule based human errors would not be influenced by IT

32 Evaluation of effects and impact of IT: PRISMA and HFMEA Theoretical predictions could be reinforced by predictive risk analysis, such as HFMEA Empirical evaluation of actual impact of IT by means of intensified incident reporting Comparison of causal patterns of incidents that occur before, during, and after the IT intervention

33 Conclusion (1) IT often mentioned as prerequisite for reduction of medication errors Results regarding effects of IT vary greatly Effects of IT on behavioural mechanisms are not/hardly taken into account PRISMA and HFMEA offer a framework for in-depth analysis of impact of IT

34 Conclusion (2) Two types of predictions can be made of expected effects of IT on error and error recovery: –Theoretical predictions by means of PRISMA –HFMEA scenario-based predictions Intensified incident reporting and analysis would enable a fast comparison between predicted and actual effects On-line corrections of implementation process could prevent actual adverse events

35 Thank you for your attention


Download ppt "I ntegration of predictive and retrospective risk analysis in health care Tjerk van der Schaaf Leiden University Medical Center Eindhoven University of."

Similar presentations


Ads by Google