TY - JOUR
T1 - Safety through redundancy
T2 - A case study of in-hospital patient transfers
AU - Ong, Mei Sing
AU - Coiera, Enrico
PY - 2010/10
Y1 - 2010/10
N2 - Objectives To study the extent and execution of redundant processes during inpatient transfers to Radiology, and their impact on errors during the transfer process; to explore the use of causal and reliability analyses for modelling error detection and redundancy in the transfer process; and to provide guidance on potential system improvements. Methods A prospective observational study at a metropolitan teaching hospital. 101 patient transfers to Radiology were observed over a 6-month period, and errors in patient transfer process were recorded. Fault Tree Analysis was used to model error paths and identify redundant steps. Reliability Analysis was used to quantify system reliability. Results 420 errors were noted, an average of four errors per transfer. No incidents of patient harm were recorded. Inadequate handover was the most common error (43.1%), followed by failure to perform patient identification checks (41.9%), patient inadequately prepared for transfer (7.4%), inadequate infection control precautions (2.9%), inadequate clinical escort (2.1%), inadequate transport vehicle (2.1%) and equipment failure (0.2%). Four redundant steps for communicating patients' infectious status were identified (reliability=0.07, 0.37, 0.26, 0.31). Collectively, these yielded a system reliability of 0.7. The low reliability of each individual step was due to its low rate of execution. Conclusions Analysis of the transfer process revealed a number of redundancies that safeguard against transfer errors. However, they were relatively ineffective in preventing errors, due to the poor compliance rate. Thus, the authors advocate increasing compliance to existing redundant processes as an improvement strategy, before investing resources on new processes.
AB - Objectives To study the extent and execution of redundant processes during inpatient transfers to Radiology, and their impact on errors during the transfer process; to explore the use of causal and reliability analyses for modelling error detection and redundancy in the transfer process; and to provide guidance on potential system improvements. Methods A prospective observational study at a metropolitan teaching hospital. 101 patient transfers to Radiology were observed over a 6-month period, and errors in patient transfer process were recorded. Fault Tree Analysis was used to model error paths and identify redundant steps. Reliability Analysis was used to quantify system reliability. Results 420 errors were noted, an average of four errors per transfer. No incidents of patient harm were recorded. Inadequate handover was the most common error (43.1%), followed by failure to perform patient identification checks (41.9%), patient inadequately prepared for transfer (7.4%), inadequate infection control precautions (2.9%), inadequate clinical escort (2.1%), inadequate transport vehicle (2.1%) and equipment failure (0.2%). Four redundant steps for communicating patients' infectious status were identified (reliability=0.07, 0.37, 0.26, 0.31). Collectively, these yielded a system reliability of 0.7. The low reliability of each individual step was due to its low rate of execution. Conclusions Analysis of the transfer process revealed a number of redundancies that safeguard against transfer errors. However, they were relatively ineffective in preventing errors, due to the poor compliance rate. Thus, the authors advocate increasing compliance to existing redundant processes as an improvement strategy, before investing resources on new processes.
UR - http://www.scopus.com/inward/record.url?scp=78249272003&partnerID=8YFLogxK
UR - http://purl.org/au-research/grants/nhmrc/568612
UR - http://purl.org/au-research/grants/arc/LP0775532
U2 - 10.1136/qshc.2009.035972
DO - 10.1136/qshc.2009.035972
M3 - Article
C2 - 20671076
AN - SCOPUS:78249272003
SN - 1475-3898
VL - 19
SP - 1
EP - 7
JO - Quality and Safety in Health Care
JF - Quality and Safety in Health Care
IS - 5
M1 - e32
ER -