Use Hazard Analysis to Improve Patient Safety

Use Hazard Analysis to Improve Patient Safety

By: Patrice L. Spath
Brown-Spath & Associates

Health care facilities have had safety programs in place for many years. These programs are intended to provide a safe and healthy environment in which hazards are eliminated or minimized for employees, staff, patients, and visitors. Several activities fall under the umbrella of the safety program including emergency preparedness, hazardous materials management, infection prevention and control, radiation safety, environmental safety and hygiene, security, utility systems management, and preventive maintenance.

However, even the best emergency evacuation plan or the most exacting preventive maintenance schedule cannot guard against the possibility of simple human error. Health care is a complex system and the people who work in this system make mistakes. While performing routine daily patient care activities people can make an occasional "slip." Human errors can also occur at the decision-making level. A comprehensive patient safety program must look for ways to help caregivers do a better job of coping with the complex world of health care delivery.

To prevent human errors in patient care processes you first need to understand the potential for error occurrence and consequences. This involves an examination of process operations and the environment, commonly called a "hazard analysis." Information for this examination is based primarily on observation of the current process (e.g., simulations, walk-throughs, or talk-throughs), operational experience (e.g., examination of past incidents and errors), and prediction of anticipated adverse patient events.

Hazard analysis is a technique used to review information about a process to determine how safe it is for patients. Such information can be used to:

Identify potential hazards and the conditions that can lead to them, so that the hazards can be eliminated or controlled.
Examine an existing process to improve its safety and to formulate appropriate operational changes.

To understand what is meant by hazard analysis, you must first understand what is a process. Simply stated, a process is an orderly arrangement of inter-related tasks that act and interact to perform some function within a particular environment and within a particular time period. In a patient-safe process, all components function in a manner that contributes to or complements task achievement. In a process that places patients at risk of an adverse event some "faults" exist. A fault is any factor that inhibits task achievement.

Conduct Periodic Hazard Analyses

Processes tend to be dynamic entities. Personnel, procedures and equipment are constantly changing and people adapt tasks to their own needs. Formal checks and balances can be abandoned as processes change over time. That's why periodic hazard analysis of high-risk processes is so important.

Hazard analysis is often a formalized process involving a qualified team leader and an experienced team. However, for all analyses a formalized process may not be practical. Some methods can be implemented by as few as one or two people when the process is fairly simple. A central issue in all hazard identification techniques is that of completeness – assuring that the list of hazards is as exhaustive as possible. One way to do this is by putting together a multi-disciplinary process evaluation team. The combined experience of the team members will provide better assurance that no important hazards are overlooked. Another way of ensuring completeness is to use more comprehensive techniques for those processes that are highest risk.

In the new publication from Brown-Spath & Associates, Patient Safety Improvement Guidebook, you'll find out how to conduct a hazard analysis of a high-risk patient care process. Included in the book are a variety of formal and informal hazard analysis techniques that can be put to immediate use in a health care organization. Once the hazards in high-risk patient care processes are understood improvement efforts can be focused on the areas of weakness in process design and the environment.

To learn more about the book, Patient Safety Improvement Guidebook, visit the product page of the Brown-Spath & Associates' web site at: http://www.brownspath.com. To receive a complimentary catalog of all publications available from Brown-Spath & Associates call (503) 357-9185.

(April 2000)

Do You Want to Learn More About This Subject? Patrice L. Spath is available for in-house presentations on this and other health care quality and resource management topics. For further details visit the Brown-Spath & Associates' web site at: http://www.brownspath.com.

Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.