Promoting patient safety through prospective risk identification: example from peri-operative care

Abstract Purpose Hip hemiarthroplasty (HA) is a commonly performed operation. A post-operative radiograph forms part of the routine hip fracture pathway, although patients are often mobilised prior to this investigation. This study seeks to provide evidence for a pragmatic clinical change to optimise patient safety and allocate limited resources within the National Health Service (NHS). Methods We undertook a retrospective database review of 1563 HA procedures to assess whether the routine ordering of check radiographs played an important role in a patient’s post-operative care. Results 18 (1.2%) mechanical complications led to a return to theatre within 6 weeks of the index procedure. All were dislocations. Ten had a normal post-operative radiograph and five had documented suspicion of dislocation prior to radiography. The post-operative check radiograph was the sole identifier of dislocation in only three patients (0.2%). All three of these patients were pre-morbidly bed bound and non-communicative due to cognitive impairment (AMTS 0/10). Conclusion Unless a patient is pre-morbidly bed bound and cognitively impaired, routine post-operative radiography following HA surgery is of little clinical benefit, yet may carry considerable risk to the patient and cost to the NHS. A pragmatic compromise is to perform intra-operative fluoroscopic imaging.

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Applying the Heuristic to the Risk Assessment within the Automotive Industry Supply Chain

Open Engineering ◽

10.1515/eng-2017-0007 ◽

2017 ◽

Vol 7 (1) ◽

pp. 43-49 ◽

Cited By ~ 1

Author(s):

Daniela Marasova ◽

Miriam Andrejiova ◽

Anna Grincova

Keyword(s):

Risk Management ◽

Supply Chain ◽

Automobile Industry ◽

Risk Identification ◽

Strategic Decision ◽

Strategic Factor ◽

Identification Evaluation ◽

Key Factor ◽

The Subject ◽

Prospective Risk

AbstractRisk management facilitates risk identification, evaluation, control, and by means of appropriate set of measures, risk reduction or complete elimination. Therefore, the risk management becomes a strategic factor for a company’s success. Properly implemented risk management system does not represent a tool to avoid the risk; it is used to understand the risk and provide the bases for strategic decision-making.Risk management represents a key factor for the supply chain operations. Managing the risks is crucial for achieving the customer satisfaction and thus also a company’s success. The subject-matter of the article is the assessment of the supply chain in the automobile industry, in terms of risks. The topicality of this problem is even higher, as after the economic crisis it is necessary to revaluate the readiness of the supply chain for prospective risk conditions. One advantage of this article is the use of the Saaty method as a tool for the risk management within the supply chain.

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The link between healthcare risk identification and patient safety culture

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-04-2018-0098 ◽

2019 ◽

Vol 32 (3) ◽

pp. 574-587 ◽

Cited By ~ 7

Author(s):

Mecit Can Emre Simsekler

Keyword(s):

Patient Safety ◽

Safety Culture ◽

Patient Safety Culture ◽

Risk Identification ◽

Content Type ◽

Safety Risks ◽

Identification Practices ◽

The Relationship ◽

Current Risk ◽

Tools And Methods

PurposeRisk identification plays a key role identifying patient safety risks. As previous research on risk identification practices, as applied to patient safety, and its association with safety culture is limited, the purpose of this paper is to evaluate current practice to address gaps and potential room for improvement.Design/methodology/approachThe authors carry out interview-based questionnaires in one UK hospital to investigate real-world risk identification practices with eight healthcare staff, including managers, nurses and a medical consultant. Considering various aspects from both risk identification and safety culture practices, the authors investigate how these two are interrelated.FindingsThe interview-based questionnaires were helpful for evaluating current risk identification practices. While gaining significant insights into risk identification practices, such as experiences using current tools and methods, mainly retrospective ones, results also explicitly showed its link with the safety culture and highlighted the limitation in measuring the relationship.Originality/valueThe interviews addressed valuable challenges affecting success in the risk identification process, including limitations in safety culture practice, training, balancing financial and safety concerns, and integrating risk information from different tools and methods.

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Control of Clinical Laboratory Errors by FMEA Model

10.5772/intechopen.97602 ◽

2021 ◽

Author(s):

Hoda Sabati ◽

Amin Mohsenzadeh ◽

Nooshin Khelghati

Keyword(s):

Patient Safety ◽

Error Detection ◽

Clinical Laboratory ◽

Technical Specification ◽

Fundamental Principle ◽

Management Plan ◽

Technical Committee ◽

Effect Analysis ◽

Medical Laboratories ◽

Prospective Risk

Patient safety is an aim for clinical applications and is a fundamental principle of healthcare and quality management. The main global health organizations have incorporated patient safety in their review of work practices. The data provided by the medical laboratories have a direct impact on patient safety and a fault in any of processes such as strategic, operational and support, could affect it. To provide appreciate and reliable data to the physicians, it is important to emphasize the need to design risk management plan in the laboratory. Failure Mode and Effect Analysis (FMEA) is an efficient technique for error detection and reduction. Technical Committee of the International Organization for Standardization (ISO) licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. FMEA model helps to identify quality failures, their effects and risks with their reduction/elimination, which depends on severity, probability and detection. Applying FMEA in clinical approaches can lead to a significant reduction of the risk priority number (RPN).

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Evaluating inputs of failure modes and effects analysis in identifying patient safety risks

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-12-2017-0233 ◽

2019 ◽

Vol 32 (1) ◽

pp. 191-207 ◽

Cited By ~ 8

Author(s):

Mecit Can Emre Simsekler ◽

Gulsum Kubra Kaya ◽

James R. Ward ◽

P. John Clarkson

Keyword(s):

Patient Safety ◽

Failure Modes ◽

Systems Approach ◽

Improve Patient Safety ◽

Risk Identification ◽

Formal Structure ◽

Potential Contribution ◽

Content Type ◽

Identification Process ◽

Safety Risks

Purpose There is a growing awareness on the use of systems approaches to improve patient safety and quality. While earlier studies evaluated the validity of such approaches to identify and mitigate patient safety risks, so far only little attention has been given to their inputs, such as structured brainstorming and use of system mapping approaches (SMAs), to understand their impact in the risk identification process. To address this gap, the purpose of this paper is to evaluate the inputs of a well-known systems approach, failure modes and effects analysis (FMEA), in identifying patient safety risks in a real healthcare setting. Design/methodology/approach This study was conducted in a newly established adult attention deficit hyperactivity disorder service at Cambridge and Peterborough Foundation Trust in the UK. Three stakeholders of the chosen service together with the facilitators conducted an FMEA exercise along with a particular system diagram that was initially found as the most useful SMA by eight stakeholders of the service. Findings In this study, it was found that the formal structure of FMEA adds value to the risk identification process through comprehensive system coverage with the help of the system diagram. However, results also indicates that the structured brainstorming refrains FMEA participants from identifying and imagining new risks since they follow the process predefined in the given system diagram. Originality/value While this study shows the potential contribution of FMEA inputs, it also suggests that healthcare organisations should not depend solely on FMEA results when identifying patient safety risks; and therefore prioritising their safety concerns.

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Prospective risk assessments of patient safety events related to drug shortages in hospitals: Three actor-level perspectives

Exploratory Research in Clinical and Social Pharmacy ◽

10.1016/j.rcsop.2021.100055 ◽

2021 ◽

pp. 100055

Author(s):

Joo Hanne Poulsen ◽

Marianne Hald Clemmensen ◽

Lotte Stig Nørgaard ◽

Peter Dieckmann

Keyword(s):

Patient Safety ◽

Risk Assessments ◽

Drug Shortages ◽

Prospective Risk

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Adaptation of the Human Factors Analysis and Classification System to Patient Safety Studies

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care ◽

10.1177/2327857913021021 ◽

2013 ◽

Vol 2 (1) ◽

pp. 108-113

Author(s):

Ronald B. Hoffman ◽

Cindy G. Segal ◽

Julie A. Foster ◽

Laura C. Rhoads

Keyword(s):

Patient Safety ◽

Human Factors ◽

Classification System ◽

Risk Identification ◽

Adverse Outcomes ◽

Hospital Environment ◽

Healthcare Organizations ◽

Factors Analysis ◽

Safety Studies ◽

Human Factors Analysis

Reliably analyzing and aggregating the gaps that lead to adverse outcomes in patient care has been difficult. We have modified and integrated the Human Factors Analysis and Classification System (HFACS) into the patient safety analyses of events at a large university cancer hospital environment to guide the development and implementation of interventions and to reduce medical errors. HFACS provides a systematic way to represent the qualitative findings of patient safety studies in a categorical database. Consistent application of this human factors tool and successive analyses of aggregated data from medical events offers healthcare organizations an objective guide for enhancements of safety risk identification and assessment systems.

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Systems for Risk Identification as a Stage of Healthcare Risk Management

Journal of Health Development ◽

10.32921/2225-9929-2021-1-41-31-38 ◽

2021 ◽

Vol 1 (41) ◽

pp. 31-38

Author(s):

Gaukhar Alzhaxina ◽

◽

Gulnar Kurenkeyeva ◽

Keyword(s):

Health Care ◽

Risk Management ◽

Patient Safety ◽

Environmental Changes ◽

Risk Identification ◽

Incident Report ◽

Healthcare Organizations ◽

Safety Incident ◽

Patient Safety Incident ◽

System Risk

The relevance of studying the issues of risk management is also associated with environmental changes, both external and internal. In connection with the COVID-19 pandemic, healthcare organizations faced new risks related to the safety of patients and staff, the activities of the healthcare organization itself in the context of the spread of a global, previously unknown infection. The article discusses approaches to methods of identifying risks associated with medical activities in the system of Kazakhstan and foreign healthcare. Keywords: Health care system, Risk Management, Patient Safety, Incident, Incident report

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Risk identification of a hospital laboratory pre-analytics through failure mode and effect analysis

Asian Journal of Medical Sciences ◽

10.3126/ajms.v12i4.33380 ◽

2021 ◽

Vol 12 (4) ◽

pp. 31-38

Author(s):

Debdatta Das ◽

Krishna Pal ◽

Sudip Roy ◽

Moushumi Lodh

Keyword(s):

Patient Safety ◽

Failure Mode ◽

Laboratory Testing ◽

Failure Modes ◽

Risk Identification ◽

Post Intervention ◽

Effect Analysis ◽

Laboratory Errors ◽

Corrective Actions ◽

Analytical Phase

Background: Implementing an active system to identify, monitor and manage risk from laboratory errors can enhance patient safety and quality of care. Aims and Objectives: Failure Mode and Effect Analysis (FMEA) technique allows evaluating and measuring the hazards of a process malfunction, to decide where to execute improvement actions, and to measure the outcome of those actions. The aim of this study was to assess pre analytical phase of laboratory testing, mitigate risk and thereby increase patient safety. Materials and Methods: Steps followed in the study were: planning the study, selecting team members, analysis of the processes, risk analysis, and developing a risk reduction protocol by incorporating corrective actions. A Fault Tree Analysis diagram was used to plot the cascade of faults leading to the pre analytical errors. Risk Priority Number (RPN) was assigned. A minimum cut- off 40 RPN was considered for interventions and highest RPN errors were prioritized with corrective actions. Post intervention RPN score was calculated. Results: Eight failure modes had the highest RPN. Corrective actions were prioritized against these errors. RPN scores of test ordering error, sample collection error, transport errors, error in patient identification, site selection, urine samples not received, sample accessioning and sample processing errors decreased, post intervention. Conclusion: With thorough planning, we can use FMEA as a common standard to analyze risk in pre analytical phase of laboratory testing.

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