Contenu connexe Similaire à Risk analysis and control nhsiq 2014 (20) Plus de NHS Improving Quality (20) Risk analysis and control nhsiq 20141. © NHS Improving Quality 2014
Risk Analysis and Control
Patient Safety Team
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“Unfortunately, I think historically the way a lot
of issues have been identified has been in a
reactive fashion, after something has occurred.”
(Duke CEO)
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Safety Assessment
• Enhancing the reliability of processes usually forms part of a detailed safety
assessment
• The aim of Safety Assessment (SA) is the identification and control of risks
• SA forms part of an organisational Safety Management System (SMS)
• The aim of the SMS is to identify and control known hazards (SA), to monitor safety
performance, to learn safety lessons and to identify novel risks.
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Scope of Safety
Management System
G: System is safe
Risk from hazards is
reduced to an
acceptable level
Risk control
interventions are
implemented and
operational
Novel risks are
identified and
assessed
FMEA Proposed
intervention
Incident
reporting
Risk
monitoring
0
10
20
30
40
50
60
Jan Feb Mar Apr May June
Dose
Frequency
Drug
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Resilience
G: System is safe
Risk from hazards is
reduced to an
acceptable level
Risk control
interventions are
implemented and
operational
Novel risks are
identified and
assessed
Intrinsic resilience
adequate
Culture of safety
established
Pro-active risk
monitoring
established
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The Tools / Approaches
Approach Step Use
Process Mapping System Definition •Document actual process
•Create shared understanding
•Basis for analysis
Failure Mode and
Effects Analysis
Risk Analysis •Proactively identify risks
•Prioritise risks and efforts
Redundancy Risk Control •Prevent failures
•Failure detection
•Mitigate consequences of failures
Primo –software
program
Risk Monitoring •Proactively identify processes that may lead
to latent conditions
•Prioritise efforts
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Failure Modes and
Effects Analysis (FMEA) &
Root Cause Analysis
• RCA is a retrospective method (process) to understand what
went wrong and why. It is applied after an adverse event has
happened.
• FMEA is a proactive method to understand how things could go
wrong and what could be the consequences of failure. It is
applied before things go wrong to prevent them from going
wrong.
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FMEA is a …………….
• systematic method of identifying and preventing product and
process problems before they occur.
• Way of focussing on the prevention of
– Defects
– Enhancing safety
– Increasing customer satisfaction
Ideally this is done when designing the process BUT FMEA on
existing processes is equally valid
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FMEA
• Systematically identify ways in which the system can cause harm
(hazard identification)
• Assessment of those situations for the risk they pose (risk analysis)
• Particularly useful for detecting conditions where a single failure
can result in a dangerous situation
• Prioritise risks to focus on those situations that pose the highest risk
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FMEA Process
1. Select Step
2. Apply Failure Mode
3. Identify Causes
4. Determine Consequences
5. Assess Risk
7. Assess Acceptability
6. Determine Mitigation
Next Step
Next Failure
Mode
If risk is not
acceptable, determine
further mitigation
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FMEA Template
Step Failure
Mode
Causes Consequences
Risk
MitigationFreq * Sev*Det = Risk
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Variation: Detection
Step Failure
Mode
Causes Consequences
Risk
Mitigation
Freq * Sev * Det = Risk
Risk Component Low High
Frequency 1 5
Severity 1 5
Detection 5 1
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EXAMPLE
Step Failure
Mode
Causes Consequences Risk
Freq x sevxdet
= risk
Mitigation
Establish
Medication
History
Failure to
identify the
medicines
that the
patient is
taking at
home
Patient
confused
about
medication
Relatives not
available
Medical
notes not
available
Patient did
not bring
medicines to
the hospital
Wrong medicine
or dose
prescribed
Omission of
required
medication
4x3x1=12 Raise
awareness in
community
for patients to
bring their
current
medicines into
the hospital
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EXERCISE
• Using your process map complete the FMEA
for your process.
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Failure Detection
(Redundancy) & Mitigation
• Using the strategies discussed earlier, we can
reduce human error, but we will never be able
to eliminate it.
• We need ways of coping with (mitigating)
failures in our systems and processes
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Why was there a hole on the road in the first place?!
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Redundancy & Diversity: Defences in depth
Violations & latent failures: Safety Management & Safety
Culture
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Redundancy
• Failure detection and mitigation are
achieved by some form of redundancy
• Having a system that is more complex than
that needed simply to perform the task
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REDUNDANCY &
MITIGATION
Failure Occurs Adverse Event
Failure Occurs Adverse Event
Mechanism
To prevent
Failure
Mechanism to
Detect and
Recover from
Failure
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Common Failure Detection Mechanisms
Make failures visible:
Self-soiling mattress
Checking:
Double checking
Information redundancy:
Diverse patient identifiers
Consistency check:
Does the medication dose make sense?
Loopback testing:
Reading back on the phone
Watchdog timer:
If results have not come back within an hour, query the lab
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Common Barrier Systems
Procedural / Cultural:
Procedures e.g peer pressure for hand hygiene
Symbolic:
Signs e.g. hand hygiene when entering wards
Functional:
Must fulfill a pre-condition before progressing
e.g. Keyboard will stop working if not wiped regularly
Physical:
Isolation of patients
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Some Problems With Redundancy
• Redundant steps have to be independent, but
often are not
Over-reliance:
• On people: double-checking
• On machines: mammography reading
– Cultural aspects: hierarchy
– Unclear allocation of responsibility
• Increased system complexity
– New failure modes
– Unanticipated interactions
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Process Map &
Standardisation
Identify and
Prioritise Risk
Barriers and
Mitigation
Test and Refine
Deliberate reliable design
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EXERCISE
• Design a redundancy for your process.