Probabilistic Risk Assessment of Accidental ABO-Incompatible Thoracic Organ Transplantation Before and After 2003

Cook, Richard I.; Wreathall, John; Smith, Alison; Cronin, David; Rivero, Oswaldo; Harland, Robert C.; Raman, Jai; Battles, James B

doi:10.1097/01.tp.0000295931.39616.25

Cited by 15 publications

(9 citation statements)

References 7 publications

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“…One way of dealing with this challenge is to simply limit the application of HRA techniques to those clinical processes or tasks, which do not fall into this category. For example, Cook and colleagues performed a PSA to quantitatively assess the likelihood of unintentional ABO-incompatible (wrong blood type) thoracic organ transplant [79]. The blood type matching process is complicated, but a national standard exists.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

On the application of Human Reliability Analysis in healthcare: Opportunities and challenges

Sujan

Embrey

Huang

2020

Reliability Engineering & System Safety

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A note on versions:The version presented here may differ from the published version or, version of record, if you wish to cite this item you are advised to consult the publisher's version. Please see the 'permanent WRAP url' above for details on accessing the published version and note that access may require a subscription.For more information, please contact the WRAP Team at: wrap@warwick.ac.uk ACCEPTED MANUSCRIPT A C C E P T E D M A N U S C R I P TResearch Highlights: Experience-based analysis of opportunities and challenges for using HRA in health  Considers reliability, performance variability, regulator, and patient role  HRA should have clinical engagement and patient participation  HRA cost-effectiveness should be rigorously evaluated  HRA can provide requisite imagination and build social safety infrastructure Abstract: Safety in healthcare is a relatively recent field, but has received considerable attention over the past 15 years. Healthcare organisations have been encouraged to learn from safety management practices in other industries. In this paper we analyse opportunities and challenges for the application of Human Reliability Analysis (HRA) in healthcare. We consider the poor levels of reliability of many healthcare processes, performance variability, the absence of regulatory frameworks that incentivise proactive risk management, and the unique role of the patient. We conclude that HRA could provide a useful framework for the analysis and reduction of risk in healthcare, but techniques might have to be adapted and applied with due consideration of the specifics of the cultural and regulatory context of this domain. This includes clinical engagement with and ownership of the HRA process, greater focus on rigorous evaluation of costeffectiveness of HRA techniques, and active involvement of patients.

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Section: Accepted Manuscriptmentioning

confidence: 99%

On the application of Human Reliability Analysis in healthcare: Opportunities and challenges

Sujan

Embrey

Huang

2020

Reliability Engineering & System Safety

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“…However, there has been limited research examining the range of patient safety vulnerabilities that occur in transplantation. While safety events such as ABO-incompatible organ transplantation,[72] infection,[73] organ rejection, and complications after surgery[74] have been reported, a systematic review of the literature on patient safety in transplantation found that the majority of articles are based on expert opinions, not data. [75*] The relative lack of empirical patient safety data for the multidisciplinary and complex field of surgery stands in stark contrast to other high risk industries such as air and land transportation, where safety vulnerability assessments are routinely performed, analyzed, and lead to continuous process improvement.…”

Section: Patient Safetymentioning

confidence: 99%

Quality of life, risk assessment, and safety research in liver transplantation

Butt

Parikh

Skaro

et al. 2012

Current Opinion in Organ Transplantation

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Purpose of review In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research: quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes. Recent findings After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well-being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high risk industries, where such assessments inform continuous process improvement. Summary Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.

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“…The identified faults are arranged in a hierarchy to demonstrate their interaction and identify areas of vulnerability. In an effort to further understand various healthcare processes, researchers have used FTA along with other PRA methodology tools to evaluate a range of medical errors and adverse events (10–12). …”

Section: Methodsmentioning

confidence: 99%

Applying fault tree analysis to the prevention of wrong-site surgery

Abecassis

McElroy

Patel

et al. 2015

Journal of Surgical Research

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Wrong Site Surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS, and used the results to perform a fault tree analysis in order to assess the reliability of the system in preventing (WSS) and identify high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for Wrong Site Surgery. The fault tree contains 35 faults, the majority of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing and a brief timeout, a large proportion of the process relies on human transcription and verification. Fault Tree Analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

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Probabilistic Risk Assessment of Accidental ABO-Incompatible Thoracic Organ Transplantation Before and After 2003

Cited by 15 publications

References 7 publications

On the application of Human Reliability Analysis in healthcare: Opportunities and challenges

On the application of Human Reliability Analysis in healthcare: Opportunities and challenges

Quality of life, risk assessment, and safety research in liver transplantation

Applying fault tree analysis to the prevention of wrong-site surgery

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