On the CUSP: STOP BSI Identifying Hazards

1. On the CUSP: STOP BSI Identifying Hazards

2. Learning Objectives • To learn how to identify hazards in a system • To learn different risk analysis methods and risk management strategies

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

4. 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

5. Hazard and Risk Analysis Tools - Reactive • Archival records • Event reporting • Root cause analysis

6. Identifying Hazards- Proactive • Work system analysis or process mapping • Observations • Interviews or focus groups • Brainstorming • Heuristic analysis

7. What to Observe? • Information tool characteristics • Extreme, unexpected, unfamiliar cases • Feedback mechanisms • Variations in conducting tasks • Fit to the job (e.g., task-technology fit) • Physical layout • Disconnects and surprises (e.g., automation surprises) • Distractions • Ambiguities • Workarounds • Team behaviors (e.g. situation awareness, shared mental model)

8. Observation Tool for Identifying Hazards

9. 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?

10. Risk Analysis

11. Risk Reduction Strategies • Simplify and standardize when you can • Create independent checkpoints • Learn from mistakes

12. 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)

13. 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

14. 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: 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.