© 2009 On the CUSP: STOP BSI Identifying Hazards

© 2009 Learning Objectives To learn how to identify hazards in a system To learn different risk analysis methods and risk management strategies

© 2009 Safety Engineering Build safety into design of systems Proactively identify hazards in the system before errors and accidents occur Develop risk management strategies

© 2009Terminology 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

© 2009 Hazard and Risk Analysis Tools - Reactive Archival records Event reporting Root cause analysis

© 2009 Identifying Hazards- Proactive Work system analysis or process mapping Observations Interviews or focus groups Brainstorming Heuristic analysis

© 2009 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 Identifying Hazards Hazards Task People involved Tools/ technologies used Environment Organizational structure System Ambiguities Workarounds Trigger(s) for hazard Consequences Risk management strategies currently used

© 2009 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?

© 2009 Risk Analysis HazardsCausesSeverityFrequencyDetectability Priority score Action Responsible party Target date

© 2009 Risk Reduction Strategies Simplify and standardize when you can Create independent checkpoints Learn from mistakes

© 2009 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 Strategies

© 2009 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

© 2009References 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: Gurses et al. (2008). Systems ambiguity and guideline compliance, QSHC 17: Marx and Slonim (2003). Assessing patient safety risk before the injury occurs. QSHC. 12:ii33-ii38.