Abstract:
When even seemingly benign and routine processes fail in healthcare, people sometimes die. The profound effect on the patient’s families and the healthcare staff involved is clear (Vincent and Coulter, 2002), while further consequences are felt by the institution involved, both financially and by damage to reputation. The trend in healthcare for learning through experience of adverse events is no longer a viable philosophy (Department of Health,Sir Ian Carruthers OBE and Pauline Philip, 2006).
In order to make progress towards preventative learning, three Prospective Hazard Analysis (PHA) methods used in other industries were evaluated for use in the area of ward based healthcare. Failure Modes and Effects Analysis (FMEA), Fault Tree Analysis (FTA) and Hazard and Operability Analysis (HAZOP) were compared to each other in terms of ease of use, information they provide and the manner in which it is presented. Their results were also compared to baseline data produced through empirical research.
Oxygen Therapy was used in this research as an example of a common ward based therapy. The resulting analysis listed 186 hazards almost all of which could lead to death, especially if combined.
FTA and FMEA provided better system coverage than HAZOP and identified more hazards than were contained in the initial hazard identification method common to both techniques. FMEA and HAZOP needed some modification before use, with HAZOP requiring the most extensive adjustment. FTA has a very useful graphical presentation and was the only method capable of displaying causal linkage, but required that hazards be translated into events for analysis.
It was concluded that formal Prospective Hazard Analysis (PHA) was applicable to this area of healthcare and presented added value through a combination of detailed information on possible hazards and accurate risk assessment based on a combination of expert opinion and empirical data. This provides a mechanism for evidence based identification of hazard barriers and safeguards as well as a method for formal communication of results at any stage of an analysis. It may further provide a very valuable vehicle for documented learning through prospective analysis incorporating feedback from previous experience and adverse incidents. The clear definition of systems and processes that form part of these methods provides a valuable opportunity for learning and the enduring capture and dissemination of tacit knowledge that can be continually updated and used for the formulation of strategies for safety and quality improvement.
