What can we learn about risks in healthcare from an aggregate analysis of multiple risk assessments?

Donna M. Woods*, Jonathan Young, Jane L. Holl, Sally Reynolds, Robert Wears, Ellen Schwalenstocker, Jennifer Oelerich, Olivia Ross, Anna Torricelli

*Corresponding author for this work

Research output: Chapter in Book/Report/Conference proceedingConference proceeding contributionpeer-review

1 Citation (Scopus)

Abstract

Identification of specific paths for medical care risks is a challenge to patient safety improvement. Frequently safety vulnerabilities and risks that exist at one institution also exist at other institutions. These represent systemic fault-lines in the safety of healthcare. The objective of this study was to collect risk results were collected from across institutions and to identify generic healthcare risks to target for substantive patient safety improvement. The LEARN method was developed and applied to review (conduct a meta-analysis) of aggregated risk assessment results from multiple FMEA studies. Sixteen risk assessments were collected from different institutions across the United States. Over 400 failpoints are described. Of these, 296 had a risk priority number designating them as medium to high risk. High risk fail points (127) included: Communication, specimen collection and management, adequate clinical resources, patient identification. Clinician communication in the course of the provision of healthcare represented the largest pool of high-risk failure modes. Of the 212 failure modes causes described, four causes represent over 50%: Human error (17%); busy, distracted (16%); Inadequate procedures (9%); Lack of data/info (9%). The identified failure modes and failure mode causes from this analysis can become topics for attention for development of risk informed interventions and safe practice implementation.

Original languageEnglish
Title of host publication10th International Conference on Probabilistic Safety Assessment and Management 2010, PSAM 2010
Place of PublicationNew York
PublisherIAPSAM & ESRA
Pages2642-2649
Number of pages8
Volume3
ISBN (Print)9781622765782
Publication statusPublished - 2010
Externally publishedYes
Event10th International Conference on Probabilistic Safety Assessment and Management 2010, PSAM 2010 - Seattle, WA, United States
Duration: 7 Jun 201011 Jun 2010

Other

Other10th International Conference on Probabilistic Safety Assessment and Management 2010, PSAM 2010
CountryUnited States
CitySeattle, WA
Period7/06/1011/06/10

Keywords

  • Healthcare
  • Improvement
  • Patient safety
  • Risk assessment
  • Risk informed

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