FMEA and RCA: the mantras; of modern risk management

Senders, John W.

doi:10.1136/qshc.2004.010868

Cited by 59 publications

(35 citation statements)

References 3 publications

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“…Such actions can affect incidents, contributing factors, detection, mitigating factors or ameliorating actions, and can be pro-active or reactive. Pro-active actions may be identified by techniques such as failure mode and effects analysis [17] and probabilistic risk analysis [18], whereas reactive actions are taken in response to insights gained after incidents (e.g. root cause analysis).…”

Section: Resultsmentioning

confidence: 99%

Towards an International Classification for Patient Safety: key concepts and terms

Runciman

Hibbert

Thomson

et al. 2009

International Journal for Quality in Health Care

486

353

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BackgroundUnderstanding the patient safety literature has been compromised by the inconsistent use of language.ObjectivesTo identify key concepts of relevance to the International Patient Safety Classification (ICPS) proposed by the World Alliance For Patient Safety of the World Health Organization (WHO), and agree on definitions and preferred terms.MethodsSix principles were agreed upon—that the concepts and terms should: be applicable across the full spectrum of healthcare; be consistent with concepts from other WHO Classifications; have meanings as close as possible to those in colloquial use; convey the appropriate meanings with respect to patient safety; be brief and clear, without unnecessary or redundant qualifiers; be fit-for-purpose for the ICPS.ResultsDefinitions and preferred terms were agreed for 48 concepts of relevance to the ICPS; these were described and the relationships between them and the ICPS were outlined.ConclusionsThe consistent use of key concepts, definitions and preferred terms should pave the way for better understanding, for comparisons between facilities and jurisdictions, and for trends to be tracked over time. Changes and improvements, translation into other languages and alignment with other sets of patient safety definitions will be necessary. This work represents the start of an ongoing process of progressively improving a common international understanding of terms and concepts relevant to patient safety.

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Section: Resultsmentioning

confidence: 99%

Towards an International Classification for Patient Safety: key concepts and terms

Runciman

Hibbert

Thomson

et al. 2009

International Journal for Quality in Health Care

486

353

View full text Add to dashboard Cite

show abstract

“…Indeed, the sheer volume of incidents reported means that health care organisations tend to investigate most events superficially. For the few incidents that receive thorough investigation, the principal method is root cause analysis, which is seen as the gold standard for gaining deeper insights into the causal features of an adverse event 14 , 18 …”

Section: Discussionmentioning

confidence: 99%

Mapping the limits of safety reporting systems in health care —what lessons can we actually learn?

Thomas

Schultz²,

Hannaford³

et al. 2011

Medical Journal of Australia

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Objectives: To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system. Design and setting: Incidents relating to patient misidentification occurring between 2004 and 2008 were selected from a sample extracted from a number of Australian health services’ incident reporting systems using a manual search function. Main outcome measures: Incident type, aetiology (error type) and recovery (error‐detection mechanism). Analyses were performed to determine category saturation. Results: All 487 selected incidents could be classified according to incident type. The most prevalent incident type was medication being administered to the wrong patient (25.7%, 125), followed by incidents where a procedure was performed on the wrong patient (15.2%, 74) and incidents where an order for pathology or medical imaging was mislabelled (7.0%, 34). Category saturation was achieved quickly, with about half the total number of incident types identified in the first 13.5% of the incidents. All 43 incident types were classified within 76.2% of the dataset. Fifty‐two incident reports (10.7%) included sufficient information to classify specific incident aetiology, and 288 reports (59.1%) had sufficient detailed information to classify a specific incident recovery mechanism. Conclusions: Incident reporting systems enable the classification of the surface features of an incident and identify common incident types. However, current systems provide little useful information on the underlying aetiology or incident recovery functions. Our study highlights several limitations of incident reporting systems, and provides guidance for improving the use of such systems in quality and safety improvement.

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“…31 Risks that can be dealt with should be subjected to a quality improvement cycle (plan-do-study-act), 44 and those that cannot should be placed on a risk register 31 for future attention, and accepted and/or indemnified against. Socio-technical probabilistic risk analysis (ST-PRA) 45 and failure mode and effects analysis (FMEA) 46 represent proactive approaches to identifying problems and setting priorities. These quality and safety activities may all contribute to ''quadruple-loop'' learning shown on the side of the pyramid in fig 1 (1, 2, 3, 4).…”

mentioning

confidence: 99%

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification

Runciman

Williamson

Deakin

et al. 2006

Qual Saf Health Care

135

120

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More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to “get it right” by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.

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FMEA and RCA: the mantras; of modern risk management

Cited by 59 publications

References 3 publications

Towards an International Classification for Patient Safety: key concepts and terms

Towards an International Classification for Patient Safety: key concepts and terms

Mapping the limits of safety reporting systems in health care —what lessons can we actually learn?

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification

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