IV. APPLICABILITY OF HAZARD ANALYSIS AND SYSTEMS APPROACH TO ADVERSE EVENT PREVENTION

Croteau and Schyve21 identify essential steps in Proactive Hazard Analysis to prevent adverse events:

  1. Identify a high-risk process.

    1. History of adverse outcomes;

    2. Identified in the literature as high risk;

    3. Has several characteristics of a high-risk process;

    4. New process;

    5. Proposed redesign (such as in response to a sentinel event).

  1. Create a flowchart of the process as designed.

  2. Assess the actual implementation of the process (e.g., different locations, shifts).

  3. Identify where there is, or may be, variation in the implementation of the process; that is, what are the failure modes?

  4. For each identified failure mode, what are the possible effects?

  5. Assess the seriousness (i.e., the “criticality”) of the possible effects (e.g., delay in treatment, temporary loss of function, patient death).

  6. For the most critical effects, conduct an RCA to determine why the variation (the failure mode) leading to that effect occurs.

  7. Redesign the process and/or underlying systems to minimize risk of that failure mode or to protect the patient from the effects of that failure mode.

  8. Conduct a PHA on the redesigned process with special attention to how the redesigned steps will affect other steps in the process and whether they will continue to achieve the beneficial things that the previous design could do.

  9. Consider simulation testing of the redesigned process.

  10. Consider a pilot test of the redesigned process.

  11. Identify and implement measures of the effectiveness of the redesigned process.

  12. Implement a strategy for maintaining the effectiveness of the redesigned process over time.

The identification of failure modes and quality management deficiencies must lead to the development and institution of reasonable interventions to prevent adverse events. Multidisciplinary teams composed of an equitable mix of frontline health care workers (e.g., clinicians, safety/facility



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