1. Workshop on Best Practices for Reducing Transfusion Errors Probabilistic Risk Assessment John Grout jgrout@campbell.berry.edu www.mistakeproofing.com 706-238-7877 David Marx david@davidmarx.com www.causationtrainer.com (952) 443-5009

2. Designing Processes to Fail? “We rely on failure of all kinds being designed into many of the products we use every day, and we have come to depend upon things failing at the right time to protect our health and safety...” “We often thus encourage one mode of failure to obviate a less desirable mode.” (Petroski, 1997, page 415) John Grout

3. Design in Benign Failures. "Failure is a relative concept, and we encounter it daily in more frequent and broad-ranging ways than is generally realized. And that is a good thing, for certain types of desirable failures, those designed to happen, are ones that engineers want to succeed at effecting." (Petroski, 1997, page 416) John Grout

4. Money Well Spent......Creating a Failure  Audi 5000  Jeep Grand Cherokee John Grout

5. Fault Tree Basics OR Top Event AND Basic Failure #1 P(F 1 )=.1 Basic Failure #2 P(F 2 )=.1 Basic Failure #3 P(F 3 )=.05 Basic Failure #4 P(F 4 )=.05 Minimal Cut Set 1 MCS 2MCS 3 P(F 1 F 2 )= P(F 1 )*P(F 2 )=.01 P(top event)= P(F 1 F 2 )+ P(F 3 )+P(F 4 )=.11 John Grout

6. Converting Undesired Failures to Benign Failures (before) Table saw motor will not operate Or Electricity not reaching motor motor unable to turn properly table saw turned on prematurely Or And wrench left on spindle nut broken wire in electric cord not plugged in excessive friction inadequate lubrication anti-kickback blade guard not mounted blade insert not mounted properly Basic 1 Basic 4Basic 3 Basic 2 Basic 7Basic 6Basic 5 tie wrench to electric cord near plug install limit switch in insert cavity benign failure (aggravation only) Undesired failure (operator injury) John Grout

7. Converting Undesired Failures to Benign Failures (after) Or Electricity not reaching motor motor unable to turn properly table saw turned on prematurely Or And wrench left on spindle nut not plugged in excessive friction inadequate lubrication anti-kickback blade guard not mounted blade insert not mounted properly B1 B4 B2 Or Benign failure Undesired failure Or break in electrical connection Operator forgets to plug in B3 B3AB4A B5 broken wire in electric cord Table saw motor will not operate John Grout

8. Multiple Fault Tree Analysis  Stopping the process is a failure (albeit benign)  Causing harm is a failure (undesirable)  Mistake-proofing converts undesirable failures to benign ones John Grout

9. Thank You!