Risk Assessing Risk Assessment

Croteau, Richard J.

doi:10.1016/s1553-7250(10)36052-1

Cited by 6 publications

(4 citation statements)

References 5 publications

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“…This calls for a proactive approach, in which patient safety professionals focus on identifying and addressing risks before they cause harm. 93–100 In addition to providing a more complete picture of patient safety risks, 98 there is a key advantage to this approach from a third victim perspective: The complete lack of an emotionally-charged adverse event. In the absence of victims and even the potential for blame, participants may have a much easier time objectively assessing and improving the systems they work in, and there is far less scope for harm to the patient safety professional.…”

Section: Potential Forms Of Harm To Third Victimsmentioning

confidence: 99%

Patient safety professionals as the third victims of adverse events

Holden¹,

Card

2019

Journal of Patient Safety and Risk Management

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Harm from adverse events does not always stop with patients and their families. In recent years, attention has been drawn to the plight of second victims, the healthcare workers involved in an incident, who can also experience significant harm. But even that does not tell the whole story. This article describes how those with indirect exposure to an adverse event can become the third victims of an adverse event, and focuses on the example of patient safety professionals responsible for incident investigation and improvement activities. We outline potential sources of harm, including critical incident stress, emotional labor, abusive supervision, and competing loyalties/duties. These stressors may cause symptoms of acute stress disorder or post-traumatic stress disorder, loss of confidence, and economic harm, and may even lead patient safety professionals to leave the profession. We also propose a number of actions to prevent or reduce harm to third victims, which include extending second victim support services to patient safety professionals, redesigning the patient safety role, providing board-level and senior management leadership, creating a culture of psychological safety, and tracking metrics related to third victims. Having drawn attention to this problem, we hope the research community will move forward with an agenda to more robustly characterize the sources and types of harm third victims experience, and to test interventions aimed at preventing and mitigating that harm.

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Section: Potential Forms Of Harm To Third Victimsmentioning

confidence: 99%

Patient safety professionals as the third victims of adverse events

Holden¹,

Card

2019

Journal of Patient Safety and Risk Management

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“…Recently, the patient safety movement has made significant progress based on learning from OHS. Prospective risk assessment techniques [38][39][40][41][42] and safety checklists, [43][44][45][46] 2 approaches long used in OHS, have just begun to be adapted and adopted by the patient safety community. Both the literature and practice of healthcare risk management would benefit from an infusion of expertise from the OHS community.…”

Section: Environmental and Occupational Health And Safetymentioning

confidence: 99%

Patient safety: This is public health

Card

2014

J of Healthc Risk Manag

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Avoidable patient harm is a major public health concern, and may already have surpassed heart disease as the leading cause of death in the United States. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalized in recent years, but specialist degree programs in the field remain scarce. Healthcare organizations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement.

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“…It is also possible that because FMEA analysis depends on the participants’ ability to imagine all possible errors, failure to identify all possible errors is actually a “failure of imagination”; our capacity to anticipate all possible outcomes is limited. This finding also reinforces, as Croteau suggests, that we should continually “risk assess” our “risk assessment process.” 36 Clearly, the process of shepherding a patient from consultation to successful completion of RT, is highly complex. Given the number of steps required to ensure that radiation treatment is delivered precisely and without error, it is not surprising that all possible events were not conceptualized or anticipated using FMEA in only 170 staff hours.…”

Section: Prioritizing Risks and Implementing Risk-reduction Strategiementioning

confidence: 99%

Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action

Terezakis

Pronovost

Harris³

et al. 2011

The Joint Commission Journal on Quality and Patient Safety

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Background Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose mis-calibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur. Prioritizing Risks and Implementing Risk-Reduction Strategies Activities undertaken at the radiation oncology department at the Johns Hopkins Hospital (Baltimore) include Failure Mode and Effects Analysis (FMEA), risk-reduction interventions, and voluntary error and near-miss reporting systems. A visual process map portrayed 269 RT steps occurring among four subprocesses—including consult, simulation, treatment planning, and treatment delivery. Two FMEAs revealed 127 and 159 possible failure modes, respectively. Risk-reduction interventions for 15 “top-ranked” failure modes were implemented. Since the error and near-miss reporting system’s implementation in the department in 2007, 253 events have been logged. However, the system may be insufficient for radiation oncology, for which a greater level of practice-specific information is required to fully understand each event. Conclusions The “basic science” of radiation treatment has received considerable support and attention in developing novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible.

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Risk Assessing Risk Assessment

Cited by 6 publications

References 5 publications

Patient safety professionals as the third victims of adverse events

Patient safety professionals as the third victims of adverse events

Patient safety: This is public health

Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action

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